Basic Information
| Provider Information | |||||||||
| NPI: | 1700842721 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VAN DOLAH | ||||||||
| FirstName: | REBECCA | ||||||||
| MiddleName: | A. | ||||||||
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| Credential: | MPAS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10 ALICE PECK DAY DR | ||||||||
| Address2: | |||||||||
| City: | LEBANON | ||||||||
| State: | NH | ||||||||
| PostalCode: | 037662900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6034483121 | ||||||||
| FaxNumber: | 6034487462 | ||||||||
| Practice Location | |||||||||
| Address1: | 17 ALICE PECK DAY DR UNIT C | ||||||||
| Address2: | |||||||||
| City: | LEBANON | ||||||||
| State: | NH | ||||||||
| PostalCode: | 037662684 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6034486344 | ||||||||
| FaxNumber: | 6034483405 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2006 | ||||||||
| LastUpdateDate: | 05/08/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | 189 | NH | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer | 363A00000X | 0947 | NH | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.