Provider Demographics
NPI:1871008102
Name:HETTEBERG, REBECCA (LPN)
Entity Type:Individual
Prefix:MRS
First Name:REBECCA
Middle Name:
Last Name:HETTEBERG
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MISS
Other - First Name:REBECCA
Other - Middle Name:
Other - Last Name:PASKAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:615 ELSINORE PL STE 200
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45202-1457
Mailing Address - Country:US
Mailing Address - Phone:513-834-7063
Mailing Address - Fax:
Practice Address - Street 1:4483 US NORTH 42
Practice Address - Street 2:
Practice Address - City:MASON
Practice Address - State:OH
Practice Address - Zip Code:45040-1934
Practice Address - Country:US
Practice Address - Phone:513-834-7063
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-08
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLPN.128686.MEDS-IV164W00000X
OHLPN128686M-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH$$$$$$$$$Medicaid