Healthcare Provider Details

I. General information

NPI: 1851237903
Provider Name (Legal Business Name): REBEKAH FANCIULLO LM,CPM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/28/2026
Last Update Date: 04/28/2026
Certification Date: 04/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1076 W HAYDEN AVE
HAYDEN ID
83835-8793
US

IV. Provider business mailing address

1076 W HAYDEN AVE
HAYDEN ID
83835-8793
US

V. Phone/Fax

Practice location:
  • Phone: 208-772-2823
  • Fax: 208-625-2027
Mailing address:
  • Phone: 208-772-2823
  • Fax: 208-625-2027

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License NumberMID-157
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: