Provider Demographics
NPI:1245801604
Name:DAVIDHIZAR, REBECCA J (AGACNP-C)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:J
Last Name:DAVIDHIZAR
Suffix:
Gender:F
Credentials:AGACNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8333 NAAB RD STE 250
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260-1983
Mailing Address - Country:US
Mailing Address - Phone:317-338-5100
Mailing Address - Fax:
Practice Address - Street 1:8333 NAAB RD STE 250
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-1983
Practice Address - Country:US
Practice Address - Phone:317-338-5100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-07
Last Update Date:2024-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71011737A363LA2100X, 363LA2100X
IN28185696A163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300056365Medicaid