Healthcare Provider Details

I. General information

NPI: 1205179041
Provider Name (Legal Business Name): TANA LYNN REPELLA M.D., PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2013
Last Update Date: 08/31/2021
Certification Date: 08/31/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

740 S LIMESTONE STE L104
LEXINGTON KY
40536-3011
US

IV. Provider business mailing address

3181 SW SAM JACKSON PARK RD
PORTLAND OR
97239-3011
US

V. Phone/Fax

Practice location:
  • Phone: 859-257-3253
  • Fax: 859-257-7603
Mailing address:
  • Phone: 503-494-8211
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number55260
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: