Provider Demographics
NPI:1902903321
Name:WHITE, REBECCA L (PMHNP, FNP)
Entity Type:Individual
Prefix:MS
First Name:REBECCA
Middle Name:L
Last Name:WHITE
Suffix:
Gender:F
Credentials:PMHNP, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 722
Mailing Address - Street 2:
Mailing Address - City:TETON VILLAGE
Mailing Address - State:WY
Mailing Address - Zip Code:83025-0722
Mailing Address - Country:US
Mailing Address - Phone:307-690-4521
Mailing Address - Fax:949-695-2562
Practice Address - Street 1:690 S HWY 89 STE 201
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001-8508
Practice Address - Country:US
Practice Address - Phone:307-690-4521
Practice Address - Fax:949-695-2562
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP-629A363L00000X
MT100917363LF0000X
WY19355.0277363L00000X
MTNP-100917363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY123446300Medicaid
ID807242401Medicaid
WY123446300Medicaid
ID807242401Medicaid
Q54271Medicare UPIN