=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508664517
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MISS REBECCA TATE BALLANCE
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/05/2025
-----------------------------------------------------
Last Update Date | 03/05/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1269 N MILITARY HWY STE 3
-----------------------------------------------------
City | NORFOLK
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23502-2243
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-900-4263
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5705 WELLINGSWORTH CT
-----------------------------------------------------
City | VIRGINIA BEACH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23464-6947
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-653-8738
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 0024192829
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------