Basic Information
| Provider Information | |||||||||
| NPI: | 1710384474 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SICK | ||||||||
| FirstName: | REBECCA | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 571 SAINT JOSEPHS BLVD | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | ELMIRA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 149013230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6072712050 | ||||||||
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| Practice Location | |||||||||
| Address1: | 600 ROE AVE | ||||||||
| Address2: | |||||||||
| City: | ELMIRA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 149051629 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077377770 | ||||||||
| FaxNumber: | 6072713686 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/24/2014 | ||||||||
| LastUpdateDate: | 12/04/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 338982 | NY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | 338982 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 04039603 | 05 | NY | MEDICAID | J400268952 | 01 | NY | MEDICARE PTAN | OTHER |