Healthcare Provider Details

I. General information

NPI: 1619351020
Provider Name (Legal Business Name): REBEKAH MICKLES CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2015
Last Update Date: 12/11/2025
Certification Date: 12/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34TH STREET AND CIVIC CENTER BOULEVARD SUITE 9329
PHILADELPHIA PA
19104-4399
US

IV. Provider business mailing address

100 E PENN SQ THE WANAMAKER BUILDING, 9TH FLOOR, NORTH
PHILADELPHIA PA
19107-3323
US

V. Phone/Fax

Practice location:
  • Phone: 215-590-1858
  • Fax:
Mailing address:
  • Phone: 267-425-9320
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN597295
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: