Provider Demographics
NPI:1043690175
Name:FAYETTE, REBEKAH G (CNM, PMHNP)
Entity type:Individual
Prefix:MS
First Name:REBEKAH
Middle Name:G
Last Name:FAYETTE
Suffix:
Gender:F
Credentials:CNM, PMHNP
Other - Prefix:
Other - First Name:REBEKAH
Other - Middle Name:
Other - Last Name:TYLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNM, PMHNP
Mailing Address - Street 1:4477 W EMERALD ST STE C200
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-2074
Mailing Address - Country:US
Mailing Address - Phone:208-780-9295
Mailing Address - Fax:
Practice Address - Street 1:4477 W EMERALD ST STE C200
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-2074
Practice Address - Country:US
Practice Address - Phone:208-780-9295
Practice Address - Fax:855-490-9559
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-03
Last Update Date:2025-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID54388367A00000X, 363LP0808X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife