Provider Demographics
NPI:1962464883
Name:SMITH, REBEKAH (NP)
Entity Type:Individual
Prefix:
First Name:REBEKAH
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 VETERANS MEMORIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:EUPORA
Mailing Address - State:MS
Mailing Address - Zip Code:39744-2064
Mailing Address - Country:US
Mailing Address - Phone:662-258-7200
Mailing Address - Fax:662-258-5871
Practice Address - Street 1:1301 VETERANS MEMORIAL BLVD
Practice Address - Street 2:
Practice Address - City:EUPORA
Practice Address - State:MS
Practice Address - Zip Code:39744-2064
Practice Address - Country:US
Practice Address - Phone:662-258-7200
Practice Address - Fax:662-258-5871
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2017-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR858253363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
500001494Medicare PIN