Provider Demographics
NPI:1740691708
Name:PRIVON, REBECCA KATHRYN (FNP-C)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:KATHRYN
Last Name:PRIVON
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3277 E LOUISE DR
Mailing Address - Street 2:STE 350
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-5510
Mailing Address - Country:US
Mailing Address - Phone:208-887-9500
Mailing Address - Fax:208-887-9800
Practice Address - Street 1:4 MEDICAL BLVD
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-7230
Practice Address - Country:US
Practice Address - Phone:601-579-5444
Practice Address - Fax:601-579-3083
Is Sole Proprietor?:No
Enumeration Date:2014-05-13
Last Update Date:2016-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR895251163W00000X, 363L00000X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08388778Medicaid
MSP01361202OtherRAILROAD MEDICARE
MS361980YKFFMedicare PIN