Provider Demographics
NPI:1083145866
Name:HOLBROOK-WATKINS, REBECCA MAE (APRN)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:MAE
Last Name:HOLBROOK-WATKINS
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:424 JETT DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:KY
Mailing Address - Zip Code:41339-9621
Mailing Address - Country:US
Mailing Address - Phone:606-666-6602
Mailing Address - Fax:
Practice Address - Street 1:424 JETT DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:KY
Practice Address - Zip Code:41339
Practice Address - Country:US
Practice Address - Phone:606-666-6600
Practice Address - Fax:606-693-0534
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-23
Last Update Date:2018-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3011220363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY3011220OtherAPRN LICENSE NUMBER