Healthcare Provider Details

I. General information

NPI: 1194082602
Provider Name (Legal Business Name): KELLY NICOLE REBKOVICH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2012
Last Update Date: 01/31/2022
Certification Date: 01/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4550 LEE HWY STE B
DUBLIN VA
24084-3802
US

IV. Provider business mailing address

388 BEN BOLT AVE
TAZEWELL VA
24651-5386
US

V. Phone/Fax

Practice location:
  • Phone: 540-674-4560
  • Fax:
Mailing address:
  • Phone: 276-988-8850
  • Fax: 276-988-6050

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 Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0102203985
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: