Healthcare Provider Details

I. General information

NPI: 1083436364
Provider Name (Legal Business Name): REBEKAH CLANTON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/29/2024
Last Update Date: 09/30/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

262 LEROY GEORGE DR
CLYDE NC
28721
US

IV. Provider business mailing address

116 SUNSET HTS
CANTON NC
28716-8747
US

V. Phone/Fax

Practice location:
  • Phone: 256-684-6755
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number5025592
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number366575
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: