Provider Demographics
NPI:1952560054
Name:ETTA, REBECCA (ACPN-BC)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:ETTA
Suffix:
Gender:F
Credentials:ACPN-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2300 ROCKBROOK DR
Mailing Address - Street 2:SUITE 100 C
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75067-8181
Mailing Address - Country:US
Mailing Address - Phone:972-459-6632
Mailing Address - Fax:972-459-6626
Practice Address - Street 1:2300 ROCKBROOK DR
Practice Address - Street 2:SUITE 100 C
Practice Address - City:LEWISVILLE
Practice Address - State:TX
Practice Address - Zip Code:75067-8181
Practice Address - Country:US
Practice Address - Phone:972-459-6632
Practice Address - Fax:972-459-6626
Is Sole Proprietor?:No
Enumeration Date:2008-06-03
Last Update Date:2015-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX662521363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX211017301Medicaid
TX8F23642OtherMEDICARE PTAN