Provider Demographics
NPI:1588623540
Name:WILKES, REBECCA LYNN (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:LYNN
Last Name:WILKES
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:86 WREN ST
Mailing Address - Street 2:
Mailing Address - City:BARNWELL
Mailing Address - State:SC
Mailing Address - Zip Code:29812
Mailing Address - Country:US
Mailing Address - Phone:803-259-5762
Mailing Address - Fax:803-259-3250
Practice Address - Street 1:333 REVOLUTIONARY TRAIL
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:SC
Practice Address - Zip Code:29827
Practice Address - Country:US
Practice Address - Phone:803-632-2533
Practice Address - Fax:803-632-2451
Is Sole Proprietor?:No
Enumeration Date:2006-03-20
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCAPRN19904363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP3909Medicaid
SC19904OtherMEDICAL LICENSE
SCP01901354OtherRR MEDICARE
IN9397741OtherPHCS PID NUMBER
SCNP3909Medicaid
INS48423Medicare UPIN
IN815510FFFMedicare PIN
IN200426150Medicaid
SCSC8344Medicare PIN
IN815520QQQQMedicare PIN