Provider Demographics
NPI:1942788807
Name:HARRISON, REBECCA (NP)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:HARRISON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:395 W COUGAR BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-3334
Mailing Address - Country:US
Mailing Address - Phone:801-357-7850
Mailing Address - Fax:
Practice Address - Street 1:395 E COUGAR BLVD
Practice Address - Street 2:101
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-8460
Practice Address - Country:US
Practice Address - Phone:801-357-7850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-02
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5497556-4405363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner