Provider Demographics
NPI:1053895532
Name:REATHERFORD, REBECKA ANN (AGACNP-BC)
Entity type:Individual
Prefix:
First Name:REBECKA
Middle Name:ANN
Last Name:REATHERFORD
Suffix:
Gender:F
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:902 LAKEVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81004-3597
Mailing Address - Country:US
Mailing Address - Phone:719-557-5855
Mailing Address - Fax:719-557-5097
Practice Address - Street 1:902 LAKEVIEW AVE
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81004-3597
Practice Address - Country:US
Practice Address - Phone:719-557-5855
Practice Address - Fax:719-557-5097
Is Sole Proprietor?:No
Enumeration Date:2018-09-20
Last Update Date:2023-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0994158363LA2100X
COAPN.0994158-NP363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000182390Medicaid