Provider Demographics
NPI:1770459075
Name:REBUSTILLO, JOAN CLAIRE OBMANA
Entity type:Individual
Prefix:MS
First Name:JOAN CLAIRE
Middle Name:OBMANA
Last Name:REBUSTILLO
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 1:4055 WETZEL RD
Mailing Address - Street 2:
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13090-2146
Mailing Address - Country:US
Mailing Address - Phone:315-486-2003
Mailing Address - Fax:
Practice Address - Street 1:201 E STATE ST
Practice Address - Street 2:
Practice Address - City:HERKIMER
Practice Address - State:NY
Practice Address - Zip Code:13350-2389
Practice Address - Country:US
Practice Address - Phone:315-574-2300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-14
Last Update Date:2025-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty