Healthcare Provider Details

I. General information

NPI: 1255923637
Provider Name (Legal Business Name): REBEKAH ELLEN MELLOR KETTERMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2021
Last Update Date: 08/19/2025
Certification Date: 08/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

961 GREEN ST NW
GAINESVILLE GA
30501-3325
US

IV. Provider business mailing address

961 GREEN ST NW
GAINESVILLE GA
30501-3325
US

V. Phone/Fax

Practice location:
  • Phone: 770-534-0656
  • Fax: 770-534-9553
Mailing address:
  • Phone: 770-534-0656
  • Fax: 770-534-9553

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN195615
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: