Healthcare Provider Details

I. General information

NPI: 1477440147
Provider Name (Legal Business Name): MARANDA REBEL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2025
Last Update Date: 06/23/2025
Certification Date: 06/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 COMMODORE ST
PRATT KS
67124-2903
US

IV. Provider business mailing address

200 COMMODORE ST
PRATT KS
67124-2903
US

V. Phone/Fax

Practice location:
  • Phone: 620-450-1670
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WX0003X
TaxonomyInpatient Obstetric Registered Nurse
License Number13117382102
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: