Healthcare Provider Details

I. General information

NPI: 1710263660
Provider Name (Legal Business Name): REBECCA R KOLB NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2011
Last Update Date: 01/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 N FLOWER ST BLDG 96
SANTA ANA CA
92703-2361
US

IV. Provider business mailing address

5054 CRESTVIEW PL
RANCHO CUCAMONGA CA
91701-1262
US

V. Phone/Fax

Practice location:
  • Phone: 909-593-2581
  • Fax:
Mailing address:
  • Phone: 951-288-2473
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95010092
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number605525
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: