Provider Demographics
NPI:1245924471
Name:CARLYLE, REBEKAH JORDAN
Entity type:Individual
Prefix:
First Name:REBEKAH
Middle Name:JORDAN
Last Name:CARLYLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BEKA
Other - Middle Name:
Other - Last Name:ANOA'I
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1710 W ERIE ST APT H201
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-5649
Mailing Address - Country:US
Mailing Address - Phone:214-755-9128
Mailing Address - Fax:
Practice Address - Street 1:901 S NATIONAL AVE # PROF160
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65897-0027
Practice Address - Country:US
Practice Address - Phone:214-755-9128
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-08
Last Update Date:2023-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty