Provider Demographics
NPI:1427328616
Name:EVERETT, REBECCA LA DINE (BSRN)
Entity type:Individual
Prefix:MS
First Name:REBECCA
Middle Name:LA DINE
Last Name:EVERETT
Suffix:
Gender:F
Credentials:BSRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:146 GETTLE ROAD, ST. 1
Mailing Address - Street 2:
Mailing Address - City:AVERILL PARK
Mailing Address - State:NY
Mailing Address - Zip Code:12018
Mailing Address - Country:US
Mailing Address - Phone:518-674-7050
Mailing Address - Fax:518-674-3802
Practice Address - Street 1:146 GETTLE ROAD, ST. 1
Practice Address - Street 2:
Practice Address - City:AVERILL PARK
Practice Address - State:NY
Practice Address - Zip Code:12018
Practice Address - Country:US
Practice Address - Phone:518-674-7020
Practice Address - Fax:518-674-7052
Is Sole Proprietor?:No
Enumeration Date:2012-01-05
Last Update Date:2012-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY411152-1163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1379024Medicaid