Provider Demographics
NPI:1124785027
Name:WHITMIRE, REBECCA SUE
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:SUE
Last Name:WHITMIRE
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:PO BOX 2945
Mailing Address - Street 2:
Mailing Address - City:CLEARLAKE
Mailing Address - State:CA
Mailing Address - Zip Code:95422-2945
Mailing Address - Country:US
Mailing Address - Phone:707-953-7064
Mailing Address - Fax:
Practice Address - Street 1:14708 PALMER AVENUE
Practice Address - Street 2:
Practice Address - City:CLEARLAKE
Practice Address - State:CA
Practice Address - Zip Code:95422-2945
Practice Address - Country:US
Practice Address - Phone:707-953-7064
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-26
Last Update Date:2021-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR0166041251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA151744100OtherOWCP PROVIDER ID