Provider Demographics
NPI:1710674155
Name:RAYBORN, REBECCA ANN (PMHNP)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:ANN
Last Name:RAYBORN
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1165 DEERFIELD
Mailing Address - Street 2:
Mailing Address - City:SUMMIT
Mailing Address - State:MS
Mailing Address - Zip Code:39666-8124
Mailing Address - Country:US
Mailing Address - Phone:601-869-7330
Mailing Address - Fax:
Practice Address - Street 1:120 E MYRTLE ST
Practice Address - Street 2:
Practice Address - City:MAGNOLIA
Practice Address - State:MS
Practice Address - Zip Code:39652-2834
Practice Address - Country:US
Practice Address - Phone:601-869-7330
Practice Address - Fax:601-783-5812
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-18
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS905970363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health