1376879189 NPI number — REBEL RENEA CHRISTIAN FNP-BC

Table of content: REBEL RENEA CHRISTIAN FNP-BC (NPI 1376879189)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376879189 NPI number — REBEL RENEA CHRISTIAN FNP-BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHRISTIAN
Provider First Name:
REBEL
Provider Middle Name:
RENEA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP-BC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GILLENWATER
Provider Other First Name:
REBEL
Provider Other Middle Name:
RENEA
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1376879189
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/15/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7400 LYNN AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HAMLIN
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
25523-1138
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-524-7284
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7400 LYNN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HAMLIN
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25523-1138
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-824-5806
Provider Business Practice Location Address Fax Number:
304-824-5885
Provider Enumeration Date:
10/29/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  62507-RN 2009007356 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 3810016640 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".




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