Provider Demographics
NPI:1952792848
Name:DUNNE, REBECCA
Entity type:Individual
Prefix:MS
First Name:REBECCA
Middle Name:
Last Name:DUNNE
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 1:616 S CLINTON ST
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:MI
Mailing Address - Zip Code:49285-9570
Mailing Address - Country:US
Mailing Address - Phone:517-416-8663
Mailing Address - Fax:
Practice Address - Street 1:616 S CLINTON ST
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:MI
Practice Address - Zip Code:49285-9570
Practice Address - Country:US
Practice Address - Phone:517-416-8663
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-12
Last Update Date:2015-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAS330318291305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI45-4439277OtherITIN