Provider Demographics
NPI:1417499096
Name:KELLEY, REBECCA WILSON (CRNP)
Entity Type:Individual
Prefix:MRS
First Name:REBECCA
Middle Name:WILSON
Last Name:KELLEY
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:JEAN
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:201 MONROE ST
Mailing Address - Street 2:SUITE 1350
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36104-3735
Mailing Address - Country:US
Mailing Address - Phone:334-206-5675
Mailing Address - Fax:
Practice Address - Street 1:2350 HARGROVE RD E
Practice Address - Street 2:
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35405-2612
Practice Address - Country:US
Practice Address - Phone:205-562-6900
Practice Address - Fax:205-759-4039
Is Sole Proprietor?:No
Enumeration Date:2016-11-14
Last Update Date:2016-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-114513363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily