Provider Demographics
NPI:1588974455
Name:HERPICK, REBECCA ANNE (DOM)
Entity type:Individual
Prefix:MS
First Name:REBECCA
Middle Name:ANNE
Last Name:HERPICK
Suffix:
Gender:F
Credentials:DOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 677
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87499-0677
Mailing Address - Country:US
Mailing Address - Phone:505-325-0072
Mailing Address - Fax:505-331-2875
Practice Address - Street 1:608 E COMANCHE ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-6815
Practice Address - Country:US
Practice Address - Phone:505-325-0072
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-13
Last Update Date:2010-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMA15179Medicaid
NMA15179Medicaid