Provider Demographics
NPI:1609659382
Name:DEACON, REBELL
Entity Type:Individual
Prefix:
First Name:REBELL
Middle Name:
Last Name:DEACON
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 1:5891 RIVERTON RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43232-1650
Mailing Address - Country:US
Mailing Address - Phone:614-625-3468
Mailing Address - Fax:
Practice Address - Street 1:5891 RIVERTON RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43232-1650
Practice Address - Country:US
Practice Address - Phone:614-625-3468
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-16
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH166502164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse