Provider Demographics
NPI:1720465958
Name:HEADLEY, REBECCA HELEN
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:HELEN
Last Name:HEADLEY
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 1:1003 MALLARD WAY
Mailing Address - Street 2:
Mailing Address - City:PITTSGROVE
Mailing Address - State:NJ
Mailing Address - Zip Code:08318-9159
Mailing Address - Country:US
Mailing Address - Phone:856-689-7151
Mailing Address - Fax:
Practice Address - Street 1:1003 MALLARD WAY
Practice Address - Street 2:
Practice Address - City:PITTSGROVE
Practice Address - State:NJ
Practice Address - Zip Code:08318-9159
Practice Address - Country:US
Practice Address - Phone:856-689-7151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-27
Last Update Date:2023-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024186029363L00000X
NJ26NJ00542700363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner