Provider Demographics
NPI:1255452652
Name:CARPENTER, REBECCA LYNN (NMD)
Entity type:Individual
Prefix:DR
First Name:REBECCA
Middle Name:LYNN
Last Name:CARPENTER
Suffix:
Gender:F
Credentials:NMD
Other - Prefix:MISS
Other - First Name:REBECCA
Other - Middle Name:LYNN
Other - Last Name:SHORT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1615 E WARNER RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85284-4500
Mailing Address - Country:US
Mailing Address - Phone:480-831-5370
Mailing Address - Fax:480-820-0081
Practice Address - Street 1:1615 E WARNER RD
Practice Address - Street 2:SUITE 1
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85284-4500
Practice Address - Country:US
Practice Address - Phone:480-831-5370
Practice Address - Fax:480-820-0081
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2008-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ02-693175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZEIN 82--578360OtherEIN NUMBER