MEDICARE: MRS. REBECCA BLOSSOM NEANDER RN, CPNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0200X	Pediatric Nurse Practitioner	AP110428	TX
2	363LP2300X	Primary Care Nurse Practitioner	AP110428	TX

General Provider Information

NPI Number	:	1689937419
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. REBECCA BLOSSOM NEANDER RN, CPNP

Provider Business Mailing Address
First Line	:	PO BOX 733784
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75373-3784
Country	:	US
Telephone Number	:	682-885-1855
Fax Number	:	682-885-1396

Provider Business Practice Location Address
First Line	:	1300 W LANCASTER AVE STE 205
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76102-3490
Country	:	US
Telephone Number	:	817-336-8611
Fax Number	:	817-390-2981

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/18/2012
Last Update Date	:	05/20/2024

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