Healthcare Provider Details

I. General information

NPI: 1164838389
Provider Name (Legal Business Name): LEILA REBAI PAC, MS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LEILA KETTERMAN

II. Dates (important events)

Enumeration Date: 07/08/2014
Last Update Date: 10/29/2025
Certification Date: 10/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

271 CAREW ST
SPRINGFIELD MA
01104-2377
US

IV. Provider business mailing address

360 US HIGHWAY 1 BYP UNIT 102
PORTSMOUTH NH
03801-7105
US

V. Phone/Fax

Practice location:
  • Phone: 413-748-9137
  • Fax:
Mailing address:
  • Phone: 603-410-6700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number3121
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number7479
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number7479
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: