Healthcare Provider Details

I. General information

NPI: 1235467093
Provider Name (Legal Business Name): REBECCA SUE BORDER NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2009
Last Update Date: 10/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 N MAIN ST
ADRIAN MI
49221-1759
US

IV. Provider business mailing address

3355 GLENDALE AVE THIRD FLOOR
TOLEDO OH
43614-2426
US

V. Phone/Fax

Practice location:
  • Phone: 517-263-1800
  • Fax: 517-263-1866
Mailing address:
  • Phone: 419-383-7100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704180437
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: