Provider Demographics
NPI:1487137931
Name:PENNINGTON, REBEKAH (PA)
Entity type:Individual
Prefix:
First Name:REBEKAH
Middle Name:
Last Name:PENNINGTON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:REBEKAH
Other - Middle Name:
Other - Last Name:FINE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 745040
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-5040
Mailing Address - Country:US
Mailing Address - Phone:336-663-5220
Mailing Address - Fax:
Practice Address - Street 1:618 S MAIN ST
Practice Address - Street 2:
Practice Address - City:REIDSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27320
Practice Address - Country:US
Practice Address - Phone:336-951-4501
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-11
Last Update Date:2021-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
NC001011715363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant