Provider Demographics
NPI:1710617246
Name:DEWITT, REBECCA D
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:D
Last Name:DEWITT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BECKY
Other - Middle Name:D
Other - Last Name:DEWITT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OPTICIAN
Mailing Address - Street 1:320 SPRUCE DR
Mailing Address - Street 2:
Mailing Address - City:FRANKFORT
Mailing Address - State:KY
Mailing Address - Zip Code:40601-3933
Mailing Address - Country:US
Mailing Address - Phone:502-330-8070
Mailing Address - Fax:502-227-5731
Practice Address - Street 1:301 LEONARDWOOD RD
Practice Address - Street 2:
Practice Address - City:FRANKFORT
Practice Address - State:KY
Practice Address - Zip Code:40601-6531
Practice Address - Country:US
Practice Address - Phone:502-227-7795
Practice Address - Fax:502-227-5731
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-16
Last Update Date:2022-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY109974156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician