Provider Demographics
NPI:1639859150
Name:PETERSON, REBECCA MARIE (RN)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:MARIE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:804 W 43RD AVE
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99337-4515
Mailing Address - Country:US
Mailing Address - Phone:509-948-2343
Mailing Address - Fax:
Practice Address - Street 1:804 W 43RD AVE
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99337-4515
Practice Address - Country:US
Practice Address - Phone:509-948-2343
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-19
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTNUR-RN-LIC-179226163W00000X
IA171766163W00000X
CORN.1685920163W00000X
WI1103083-30163W00000X
WARN60765920163W00000X
KS158979163W00000X
NE96247163W00000X
NM71585163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse