Provider Demographics
NPI:1588377386
Name:CHILDS DERHAK, REBECCA (RN)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:CHILDS DERHAK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 KNIGHT ST
Mailing Address - Street 2:
Mailing Address - City:FALMOUTH
Mailing Address - State:ME
Mailing Address - Zip Code:04105-1711
Mailing Address - Country:US
Mailing Address - Phone:207-939-4196
Mailing Address - Fax:
Practice Address - Street 1:934 CONGRESS ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-3032
Practice Address - Country:US
Practice Address - Phone:207-874-2141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-27
Last Update Date:2022-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MERN66324163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse