Healthcare Provider Details

I. General information

NPI: 1780140939
Provider Name (Legal Business Name): REBECCA BERMAN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2019
Last Update Date: 05/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

38 OLD WHITE LAKE TURNPIKE
SWAN LAKE NY
12783
US

IV. Provider business mailing address

MALACHI HANAVI 10/10
BEIT SHEMESH JERUSALEM
9914123
IL

V. Phone/Fax

Practice location:
  • Phone: 347-528-5521
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number604938
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number774535
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number344366
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: