Provider Demographics
NPI:1659503472
Name:BLAIR, REBECCA L (CRNA)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:L
Last Name:BLAIR
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:DANVILLE POLYCLINIC, LTD.
Mailing Address - Street 2:707 N LOGAN AVE
Mailing Address - City:DANVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:61832-4360
Mailing Address - Country:US
Mailing Address - Phone:217-477-4794
Mailing Address - Fax:217-477-4757
Practice Address - Street 1:DANVILLE POLYCLINIC, LTD.
Practice Address - Street 2:707 N LOGAN AVE
Practice Address - City:DANVILLE
Practice Address - State:IL
Practice Address - Zip Code:61832-4360
Practice Address - Country:US
Practice Address - Phone:217-477-4794
Practice Address - Fax:217-477-4757
Is Sole Proprietor?:No
Enumeration Date:2009-08-12
Last Update Date:2017-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041318912163W00000X
IN28238046A367500000X
IL209007449367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse