Basic Information
| Provider Information | |||||||||
| NPI: | 1871992693 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RENSY-TALLARICO | ||||||||
| FirstName: | REBECCA | ||||||||
| MiddleName: | JENNIFER | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | FNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RENSY | ||||||||
| OtherFirstName: | REBECCA | ||||||||
| OtherMiddleName: | JENNIFER | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | FNP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 17 LANSING STREET | ||||||||
| Address2: | |||||||||
| City: | AUBURN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 13021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3152557438 | ||||||||
| FaxNumber: | 3152557018 | ||||||||
| Practice Location | |||||||||
| Address1: | 5496 E TAFT RD | ||||||||
| Address2: | |||||||||
| City: | NORTH SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132123784 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3155526700 | ||||||||
| FaxNumber: | 3155526701 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2014 | ||||||||
| LastUpdateDate: | 02/22/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 338788 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 03951388 | 05 | NY | MEDICAID |