Provider Demographics
NPI:1033408984
Name:THOMAS, REBECCA NICOLE (MD)
Entity Type:Individual
Prefix:DR
First Name:REBECCA
Middle Name:NICOLE
Last Name:THOMAS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MISS
Other - First Name:REBECCA
Other - Middle Name:NICOLE
Other - Last Name:WASSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:47 5TH ST NW
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33881-4672
Mailing Address - Country:US
Mailing Address - Phone:863-291-5110
Mailing Address - Fax:863-268-7899
Practice Address - Street 1:305 W CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:LAKE WALES
Practice Address - State:FL
Practice Address - Zip Code:33853-4015
Practice Address - Country:US
Practice Address - Phone:863-855-9718
Practice Address - Fax:863-855-9737
Is Sole Proprietor?:No
Enumeration Date:2011-03-31
Last Update Date:2017-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME118537207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL012316800Medicaid