Provider Demographics
NPI:1407426661
Name:DAVID, REBEKKA KELLY
Entity Type:Individual
Prefix:
First Name:REBEKKA
Middle Name:KELLY
Last Name:DAVID
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 MAGNOLIA LN
Mailing Address - Street 2:
Mailing Address - City:EAST BERLIN
Mailing Address - State:CT
Mailing Address - Zip Code:06023-1008
Mailing Address - Country:US
Mailing Address - Phone:860-937-9856
Mailing Address - Fax:
Practice Address - Street 1:18 MAGNOLIA LN
Practice Address - Street 2:
Practice Address - City:EAST BERLIN
Practice Address - State:CT
Practice Address - Zip Code:06023-1008
Practice Address - Country:US
Practice Address - Phone:860-637-9856
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-30
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTE58330163WG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0600XNursing Service ProvidersRegistered NurseGerontology