Healthcare Provider Details

I. General information

NPI: 1811731391
Provider Name (Legal Business Name): REBECCA ANN MOORE RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: REBECCA ANN STOCKMAN

II. Dates (important events)

Enumeration Date: 06/20/2024
Last Update Date: 06/20/2024
Certification Date: 06/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2101 SPRUCE ST
NORTH COLLINS NY
14111-9701
US

IV. Provider business mailing address

2101 SPRUCE ST
NORTH COLLINS NY
14111-9701
US

V. Phone/Fax

Practice location:
  • Phone: 716-337-3706
  • Fax: 716-337-2723
Mailing address:
  • Phone: 716-337-3706
  • Fax: 716-337-2723

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number719202
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: