Provider Demographics
NPI:1871992693
Name:RENSY-TALLARICO, REBECCA JENNIFER (FNP)
Entity type:Individual
Prefix:MRS
First Name:REBECCA
Middle Name:JENNIFER
Last Name:RENSY-TALLARICO
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:MRS
Other - First Name:REBECCA
Other - Middle Name:JENNIFER
Other - Last Name:RENSY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:17 LANSING STREET
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:NY
Mailing Address - Zip Code:13021
Mailing Address - Country:US
Mailing Address - Phone:315-255-7438
Mailing Address - Fax:315-255-7018
Practice Address - Street 1:5496 E TAFT RD
Practice Address - Street 2:
Practice Address - City:NORTH SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13212-3784
Practice Address - Country:US
Practice Address - Phone:315-552-6700
Practice Address - Fax:315-552-6701
Is Sole Proprietor?:No
Enumeration Date:2014-08-18
Last Update Date:2022-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY338788363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03951388Medicaid