Provider Demographics
NPI:1942659131
Name:KLACKO, REBECCA (RNFA RN FIRST ASSIST)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:KLACKO
Suffix:
Gender:F
Credentials:RNFA RN FIRST ASSIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:BOX 652
Mailing Address - Street 2:
Mailing Address - City:RIDGEWAY
Mailing Address - State:ONTARIO
Mailing Address - Zip Code:L0S1N0
Mailing Address - Country:CA
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:BOX 652
Practice Address - Street 2:
Practice Address - City:RIDGEWAY
Practice Address - State:ONTARIO
Practice Address - Zip Code:L0S1N0
Practice Address - Country:CA
Practice Address - Phone:289-407-2601
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-08
Last Update Date:2016-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY593145163WR0006X
TX839373163WR0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First Assistant