Healthcare Provider Details

I. General information

NPI: 1447641717
Provider Name (Legal Business Name): REBECCA NORDIN R.N.F.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: REBA VAN KOOTEN

II. Dates (important events)

Enumeration Date: 02/09/2015
Last Update Date: 03/17/2020
Certification Date: 03/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1909 VISTA DR
LARAMIE WY
82070-5530
US

IV. Provider business mailing address

1909 VISTA DR
LARAMIE WY
82070-5530
US

V. Phone/Fax

Practice location:
  • Phone: 307-745-8851
  • Fax:
Mailing address:
  • Phone: 307-745-8851
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License Number30868
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: