Healthcare Provider Details

I. General information

NPI: 1366068256
Provider Name (Legal Business Name): REBEKAH DANIELLE LEWIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: REBEKAH DANIELLE THOMPSON

II. Dates (important events)

Enumeration Date: 06/17/2020
Last Update Date: 09/28/2026
Certification Date: 09/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

945 W RUSSELL ST
ELKHORN CITY KY
41522-9032
US

IV. Provider business mailing address

3800 S OCEAN DR STE 209
HOLLYWOOD FL
33019-2915
US

V. Phone/Fax

Practice location:
  • Phone: 800-226-8874
  • Fax: 877-366-4776
Mailing address:
  • Phone: 800-226-8874
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9115144
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2883
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number0110009460
License Number StateVA
# 4
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: