Provider Demographics
NPI:1174240048
Name:FAIRBANKS, REBECCA LYNN (RN)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:LYNN
Last Name:FAIRBANKS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:LYNN
Other - Last Name:CUTHBERTSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:REGISTERED NURSE
Mailing Address - Street 1:4722 N TATTENHAM WAY
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83713-2528
Mailing Address - Country:US
Mailing Address - Phone:208-908-9183
Mailing Address - Fax:
Practice Address - Street 1:1112 W MAIN ST STE 106
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-5137
Practice Address - Country:US
Practice Address - Phone:208-949-9904
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-21
Last Update Date:2022-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDN-38031163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse