Provider Demographics
NPI:1255190914
Name:ANDERSON, REBA (LPN)
Entity type:Individual
Prefix:
First Name:REBA
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1429 DUDLEY HILL RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBOURNE
Mailing Address - State:WV
Mailing Address - Zip Code:26149-7803
Mailing Address - Country:US
Mailing Address - Phone:304-313-3047
Mailing Address - Fax:
Practice Address - Street 1:299 1/2 N STATE ROUTE 2
Practice Address - Street 2:
Practice Address - City:NEW MARTINSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26155-2243
Practice Address - Country:US
Practice Address - Phone:304-455-0350
Practice Address - Fax:304-455-1512
Is Sole Proprietor?:No
Enumeration Date:2024-03-15
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV30506164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse