Provider Demographics
NPI:1730686114
Name:ANDERSON, REBECCA MARIE (FNP)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:MARIE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:MARIE
Other - Last Name:JERNSTROM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 279
Mailing Address - Street 2:
Mailing Address - City:WINAMAC
Mailing Address - State:IN
Mailing Address - Zip Code:46996-0279
Mailing Address - Country:US
Mailing Address - Phone:574-946-2100
Mailing Address - Fax:
Practice Address - Street 1:540 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:WINAMAC
Practice Address - State:IN
Practice Address - Zip Code:46996-1173
Practice Address - Country:US
Practice Address - Phone:574-946-2194
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-11
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71007907A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily