Provider Demographics
NPI:1316579154
Name:VANAKEN, REBEKAH LAINE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:REBEKAH
Middle Name:LAINE
Last Name:VANAKEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:REBEKAH
Other - Middle Name:LAINE
Other - Last Name:PETTY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:13403 W 7 MILE RD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48235-1387
Mailing Address - Country:US
Mailing Address - Phone:313-308-2444
Mailing Address - Fax:
Practice Address - Street 1:13403 W 7 MILE RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48235-1387
Practice Address - Country:US
Practice Address - Phone:313-308-2444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-10
Last Update Date:2022-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI5601010283363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program