Healthcare Provider Details

I. General information

NPI: 1720972094
Provider Name (Legal Business Name): REBECCA FUNDERBURK FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2025
Last Update Date: 06/03/2025
Certification Date: 06/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1040 EDGEWATER CORPORATE PKWY STE 101
INDIAN LAND SC
29707-4526
US

IV. Provider business mailing address

3055 RICHARDS WAY DR
ROCK HILL SC
29732-8857
US

V. Phone/Fax

Practice location:
  • Phone: 803-548-7007
  • Fax:
Mailing address:
  • Phone: 803-320-0246
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number231111
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: