Provider Demographics
NPI:1255330635
Name:ZIMMERMAN, REBECCA (NP)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:ZIMMERMAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:
Other - Last Name:PEDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:2350 N ROCKTON AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61103-3600
Mailing Address - Country:US
Mailing Address - Phone:815-971-5550
Mailing Address - Fax:815-971-6825
Practice Address - Street 1:2350 N ROCKTON AVE
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61103-3600
Practice Address - Country:US
Practice Address - Phone:815-971-2000
Practice Address - Fax:815-971-6825
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2016-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209004539363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK14083Medicare ID - Type UnspecifiedLOCALITY 15
ILK14084Medicare ID - Type UnspecifiedLOCALITY 99
ILQ24896Medicare UPIN
ILK10535Medicare PIN