Provider Demographics
NPI:1154528743
Name:WHEATLEY, REBEKAH L (MD)
Entity type:Individual
Prefix:
First Name:REBEKAH
Middle Name:L
Last Name:WHEATLEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:P.O. BOX 5720
Mailing Address - Street 2:PROVIDER ENROLLMENT DEPARTMENT
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32247-5720
Mailing Address - Country:US
Mailing Address - Phone:302-651-6718
Mailing Address - Fax:407-650-7578
Practice Address - Street 1:807 CHILDRENS WAY
Practice Address - Street 2:NEMOURS CHILDRENS CLINIC, JACKSONVILLE
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8426
Practice Address - Country:US
Practice Address - Phone:904-697-3694
Practice Address - Fax:904-697-3927
Is Sole Proprietor?:No
Enumeration Date:2007-06-28
Last Update Date:2011-07-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN50184207L00000X
FLME110260207LP3000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP3000XAllopathic & Osteopathic PhysiciansAnesthesiologyPediatric Anesthesiology
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN352133000Medicaid
MN352133000Medicaid