Healthcare Provider Details

I. General information

NPI: 1114909900
Provider Name (Legal Business Name): KELLI P RABOIN
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/16/2005
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 GENERAL HOSPITAL
APO AP
96205-5244
KR

IV. Provider business mailing address

18TH MEDCOM ATTN: DCCS-AM(CREDENTIALS
APO AP
96205-0054
KR

V. Phone/Fax

Practice location:
  • Phone: 01182279174243
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR032356
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: