Healthcare Provider Details

I. General information

NPI: 1194471599
Provider Name (Legal Business Name): REBECCA MARTIN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/23/2022
Last Update Date: 02/23/2022
Certification Date: 02/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1232 HILLOCK XING
VIRGINIA BEACH VA
23455-6747
US

IV. Provider business mailing address

1232 HILLOCK XING
VIRGINIA BEACH VA
23455-6747
US

V. Phone/Fax

Practice location:
  • Phone: 757-567-5561
  • Fax:
Mailing address:
  • Phone: 757-567-5561
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License Number336812
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: