Provider Demographics
NPI:1205075272
Name:MARTIN, REBECCA (ARNP)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:
Other - Last Name:WILDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARNP
Mailing Address - Street 1:92 W MILLER ST
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-2032
Mailing Address - Country:US
Mailing Address - Phone:321-841-8588
Mailing Address - Fax:321-841-8560
Practice Address - Street 1:92 W MILLER ST
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-2032
Practice Address - Country:US
Practice Address - Phone:321-841-8588
Practice Address - Fax:321-841-8560
Is Sole Proprietor?:No
Enumeration Date:2009-02-13
Last Update Date:2016-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP1759172363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLARNP1759172OtherMEDICAL LICENSE
FL000648400Medicaid
FL000648400Medicaid