Provider Demographics
NPI:1710455720
Name:FUQUA, REBECCA (NP-C)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:FUQUA
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1139 NW BROAD ST STE 103
Mailing Address - Street 2:
Mailing Address - City:MURFREESBORO
Mailing Address - State:TN
Mailing Address - Zip Code:37129-2390
Mailing Address - Country:US
Mailing Address - Phone:423-296-2604
Mailing Address - Fax:423-296-2607
Practice Address - Street 1:1139 NW BROAD ST STE 103
Practice Address - Street 2:
Practice Address - City:MURFREESBORO
Practice Address - State:TN
Practice Address - Zip Code:37129-2390
Practice Address - Country:US
Practice Address - Phone:423-296-2604
Practice Address - Fax:423-296-2607
Is Sole Proprietor?:No
Enumeration Date:2018-11-07
Last Update Date:2018-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN25098363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner