Provider Demographics
NPI:1760526438
Name:MCINNIS, REBECCA ANN (CNM)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:ANN
Last Name:MCINNIS
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:ANN
Other - Last Name:LAURITZEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4555 CREEK LN
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-3913
Mailing Address - Country:US
Mailing Address - Phone:801-288-0087
Mailing Address - Fax:801-278-3112
Practice Address - Street 1:2180 E 4500 S
Practice Address - Street 2:SUITE 150
Practice Address - City:HOLLADAY
Practice Address - State:UT
Practice Address - Zip Code:84117-4434
Practice Address - Country:US
Practice Address - Phone:801-278-3102
Practice Address - Fax:801-278-3112
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT47473784402367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT72884OtherPEHP INSURANCE
UT4747378440001OtherBCBS INSURANCE
UTP79837Medicare UPIN