Provider Demographics
NPI:1215267018
Name:HARTZOG, REBECCA B (PMHNP)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:B
Last Name:HARTZOG
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:A
Other - Last Name:BURRIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FPMHNP
Mailing Address - Street 1:415 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7246
Mailing Address - Country:US
Mailing Address - Phone:601-261-5159
Mailing Address - Fax:601-579-5240
Practice Address - Street 1:1 LINCOLN PKWY STE 304
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-3261
Practice Address - Country:US
Practice Address - Phone:601-261-1750
Practice Address - Fax:601-261-1755
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-30
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR876189363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04973557Medicaid