Provider Demographics
NPI:1396568838
Name:SOPELAK, REBECCA ANNE
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:ANNE
Last Name:SOPELAK
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 1:4 TERRIE RD
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06032-2422
Mailing Address - Country:US
Mailing Address - Phone:860-490-4012
Mailing Address - Fax:
Practice Address - Street 1:115 WATERBURY RD
Practice Address - Street 2:
Practice Address - City:PROSPECT
Practice Address - State:CT
Practice Address - Zip Code:06712-1254
Practice Address - Country:US
Practice Address - Phone:203-758-5660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-04
Last Update Date:2024-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT12.013507363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily