Provider Demographics
NPI:1053603720
Name:WAGSTAFF, REBECCA RAE
Entity type:Individual
Prefix:MS
First Name:REBECCA
Middle Name:RAE
Last Name:WAGSTAFF
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 1:3216 E MOORE, APT. 24
Mailing Address - Street 2:
Mailing Address - City:SEARCY
Mailing Address - State:AR
Mailing Address - Zip Code:72143
Mailing Address - Country:US
Mailing Address - Phone:501-268-7777
Mailing Address - Fax:501-278-5506
Practice Address - Street 1:3216 E MOORE AVE APT 24
Practice Address - Street 2:
Practice Address - City:SEARCY
Practice Address - State:AR
Practice Address - Zip Code:72143-4894
Practice Address - Country:US
Practice Address - Phone:501-268-7777
Practice Address - Fax:501-278-5506
Is Sole Proprietor?:No
Enumeration Date:2011-05-12
Last Update Date:2011-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator