Healthcare Provider Details

I. General information

NPI: 1982025367
Provider Name (Legal Business Name): REBECCA ROSE SMITH APRN CNM CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/02/2014
Last Update Date: 07/17/2022
Certification Date: 07/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2701 W 68TH ST 3 SOUTH
CHICAGO IL
60629-1813
US

IV. Provider business mailing address

6801 COLDWATER CANYON AVE
NORTH HOLLYWOOD CA
91605-5162
US

V. Phone/Fax

Practice location:
  • Phone: 773-434-4040
  • Fax:
Mailing address:
  • Phone: 818-763-8836
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WW0101X
TaxonomyAmbulatory Women's Health Care Registered Nurse
License Number95182490
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number236017
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: