Healthcare Provider Details

I. General information

NPI: 1245924471
Provider Name (Legal Business Name): REBEKAH JORDAN CARLYLE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: BEKA ANOA'I

II. Dates (important events)

Enumeration Date: 06/08/2023
Last Update Date: 06/08/2023
Certification Date: 06/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 S NATIONAL AVE # PROF160
SPRINGFIELD MO
65897-0027
US

IV. Provider business mailing address

1710 W ERIE ST APT H201
SPRINGFIELD MO
65807-5649
US

V. Phone/Fax

Practice location:
  • Phone: 214-755-9128
  • Fax:
Mailing address:
  • Phone: 214-755-9128
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: