Provider Demographics
NPI:1356940829
Name:SMITH, REBECCA LYNNE
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:LYNNE
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1611 CLARE CT
Mailing Address - Street 2:
Mailing Address - City:NORTH MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56003-3404
Mailing Address - Country:US
Mailing Address - Phone:507-317-7308
Mailing Address - Fax:
Practice Address - Street 1:2010 ADAMS ST
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-6817
Practice Address - Country:US
Practice Address - Phone:507-625-7565
Practice Address - Fax:507-625-2606
Is Sole Proprietor?:No
Enumeration Date:2020-10-25
Last Update Date:2020-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI812431390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program