Provider Demographics
NPI:1194082602
Name:REBKOVICH, KELLY NICOLE
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:NICOLE
Last Name:REBKOVICH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:388 BEN BOLT AVE
Mailing Address - Street 2:
Mailing Address - City:TAZEWELL
Mailing Address - State:VA
Mailing Address - Zip Code:24651-5386
Mailing Address - Country:US
Mailing Address - Phone:276-988-8850
Mailing Address - Fax:276-988-6050
Practice Address - Street 1:4550 LEE HWY STE B
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:VA
Practice Address - Zip Code:24084-3802
Practice Address - Country:US
Practice Address - Phone:540-674-4560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-20
Last Update Date:2022-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA0102203985207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program