Provider Demographics
NPI:1316777691
Name:KOMARA, REBECCA LEE (FNP-C)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:LEE
Last Name:KOMARA
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41800 W 11 MILE RD STE 109
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48375-1818
Mailing Address - Country:US
Mailing Address - Phone:248-660-1220
Mailing Address - Fax:
Practice Address - Street 1:2473 NORTH RD NE
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44483-3054
Practice Address - Country:US
Practice Address - Phone:330-372-2251
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-02
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHF04240082363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily