Healthcare Provider Details

I. General information

NPI: 1871073882
Provider Name (Legal Business Name): REBECCA ELIZABETH WAHL NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2018
Last Update Date: 02/26/2020
Certification Date: 02/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

134 HOMER AVE
CORTLAND NY
13045-1206
US

IV. Provider business mailing address

730 STATE ROUTE 38
LOCKE NY
13092-4132
US

V. Phone/Fax

Practice location:
  • Phone: 607-756-3500
  • Fax:
Mailing address:
  • Phone: 315-440-6376
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number308976
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number559339
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: