Provider Demographics
NPI:1104892371
Name:ALLEN-LEGAULT, REBECCA L (FNP-BC)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:L
Last Name:ALLEN-LEGAULT
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:L
Other - Last Name:ALLEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP-BC
Mailing Address - Street 1:50755 TIMOTHY RD
Mailing Address - Street 2:
Mailing Address - City:NEW CARLISLE
Mailing Address - State:IN
Mailing Address - Zip Code:46552-9636
Mailing Address - Country:US
Mailing Address - Phone:574-210-1850
Mailing Address - Fax:574-210-1850
Practice Address - Street 1:6910 N MAIN ST UNIT 52
Practice Address - Street 2:
Practice Address - City:GRANGER
Practice Address - State:IN
Practice Address - Zip Code:46530-8412
Practice Address - Country:US
Practice Address - Phone:574-231-6766
Practice Address - Fax:833-249-2411
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-27
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71000950A363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200279550Medicaid
IN200279550Medicaid
IN955190MMMedicare ID - Type Unspecified