Provider Demographics
NPI:1801028238
Name:BLAIR, REBECCA (LVN)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:BLAIR
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:
Other - Last Name:BUCKERT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LVN
Mailing Address - Street 1:1799 HAMPTON AVE
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93611-5127
Mailing Address - Country:US
Mailing Address - Phone:559-283-1791
Mailing Address - Fax:
Practice Address - Street 1:3467 W SHAW AVE
Practice Address - Street 2:SUITE # 102
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93711-3223
Practice Address - Country:US
Practice Address - Phone:559-274-0456
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-18
Last Update Date:2009-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA220545164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse