Basic Information
| Provider Information | |||||||||
| NPI: | 1548824105 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | REBECCA | ||||||||
| MiddleName: | JANE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CNM | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
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| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 600 COMMERCE BLVD | ||||||||
| Address2: | |||||||||
| City: | STROUDSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 183606214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5704262700 | ||||||||
| FaxNumber: | 5704241252 | ||||||||
| Practice Location | |||||||||
| Address1: | 600 COMMERCE BLVD | ||||||||
| Address2: | |||||||||
| City: | STROUDSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 183606214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5704262700 | ||||||||
| FaxNumber: | 5704241252 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/29/2019 | ||||||||
| LastUpdateDate: | 06/01/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN682740 | PA | N | Nursing Service Providers | Registered Nurse | 367A00000X | MW010619 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
ID Information
| ID | Type | State | Issuer | Description | MW010619 | 01 | PA | STATE LICENSE | OTHER |