Provider Demographics
NPI:1992730998
Name:TUSTAIN, REBECCA (NP)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:TUSTAIN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1115 N FRONTAGE RD
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39180-5102
Mailing Address - Country:US
Mailing Address - Phone:601-634-8790
Mailing Address - Fax:
Practice Address - Street 1:1115 N FRONTAGE RD
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39180-5102
Practice Address - Country:US
Practice Address - Phone:601-634-8790
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR543349363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0118982Medicaid
MSS49552Medicare UPIN