Provider Demographics
NPI:1639112402
Name:KRAFTICK, REBECCA B (PA-C)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:B
Last Name:KRAFTICK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 936
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:KY
Mailing Address - Zip Code:40743-0936
Mailing Address - Country:US
Mailing Address - Phone:606-330-7818
Mailing Address - Fax:606-330-7825
Practice Address - Street 1:1401 HARRODSBURG RD
Practice Address - Street 2:SUITE A-300
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504-3751
Practice Address - Country:US
Practice Address - Phone:859-276-4429
Practice Address - Fax:859-276-5939
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2019-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA459363AM0700X
TN2588363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYC60223OtherCUMBERLAND HEALTHCARE INC
KY50010910OtherPASSPORT
TN3710089Medicaid
KY000000478148OtherANTHEM
KY95004594Medicaid
KY000000478148OtherANTHEM
KYC60223OtherCUMBERLAND HEALTHCARE INC
TN3710089Medicaid