Provider Demographics
NPI:1770391062
Name:THUNDIYATH, REBECCA
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:THUNDIYATH
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 1:1520 CALDWELL CIR
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:TX
Mailing Address - Zip Code:75010-6433
Mailing Address - Country:US
Mailing Address - Phone:469-237-0183
Mailing Address - Fax:
Practice Address - Street 1:1520 CALDWELL CIR
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:TX
Practice Address - Zip Code:75010-6433
Practice Address - Country:US
Practice Address - Phone:469-237-0183
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-19
Last Update Date:2024-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1182435363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily