Provider Demographics
NPI:1881426716
Name:MITCHAM, REBECCA LEE (AGNP-C, RN)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:LEE
Last Name:MITCHAM
Suffix:
Gender:F
Credentials:AGNP-C, RN
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 11538
Mailing Address - Street 2:
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76547-1538
Mailing Address - Country:US
Mailing Address - Phone:254-245-9175
Mailing Address - Fax:
Practice Address - Street 1:3800 S W S YOUNG DR STE 201
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76542-3340
Practice Address - Country:US
Practice Address - Phone:254-245-9175
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-19
Last Update Date:2025-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK219787363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner