Provider Demographics
NPI:1881018729
Name:KOTTKAMP, REBEKAH (FNP-BC)
Entity Type:Individual
Prefix:
First Name:REBEKAH
Middle Name:
Last Name:KOTTKAMP
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 N NILES AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-1924
Mailing Address - Country:US
Mailing Address - Phone:574-647-1610
Mailing Address - Fax:
Practice Address - Street 1:621 MEMORIAL DR STE 402
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-1074
Practice Address - Country:US
Practice Address - Phone:574-400-4550
Practice Address - Fax:574-400-4551
Is Sole Proprietor?:No
Enumeration Date:2014-02-12
Last Update Date:2019-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71004841A363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000870047OtherBCBS BMGSOUTHEAST
IN201220670Medicaid
IN178420011OtherMEDICARE PTAN
IN178410010OtherMEDICARE PTAN
INP01413900OtherRR MEDICARE
IN000000870050OtherBCBS BMG CENTENNIAL
IN000000872005OtherBCBS BMG CENTRAL
IN178410010OtherMEDICARE PTAN
IN201220670Medicaid