Healthcare Provider Details

I. General information

NPI: 1730567611
Provider Name (Legal Business Name): ALANA C. REBOLLO P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2015
Last Update Date: 06/24/2024
Certification Date: 06/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

85 POHEGANUT DR
GROTON CT
06340-3252
US

IV. Provider business mailing address

2150 MAIN STREET
SPRINGFIELD MA
01104
US

V. Phone/Fax

Practice location:
  • Phone: 860-448-6303
  • Fax:
Mailing address:
  • Phone: 413-739-5676
  • Fax: 413-733-5860

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number003299
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC5760
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC00A5760
License Number StateMD
# 4
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number3299
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: