Provider Demographics
NPI:1366068256
Name:LEWIS, REBEKAH DANIELLE
Entity type:Individual
Prefix:
First Name:REBEKAH
Middle Name:DANIELLE
Last Name:LEWIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:REBEKAH
Other - Middle Name:DANIELLE
Other - Last Name:THOMPSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3800 S OCEAN DR STE 209
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33019-2915
Mailing Address - Country:US
Mailing Address - Phone:800-226-8874
Mailing Address - Fax:
Practice Address - Street 1:945 W RUSSELL ST
Practice Address - Street 2:
Practice Address - City:ELKHORN CITY
Practice Address - State:KY
Practice Address - Zip Code:41522-9032
Practice Address - Country:US
Practice Address - Phone:800-226-8874
Practice Address - Fax:877-366-4776
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-17
Last Update Date:2025-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9115144363A00000X
363AM0700X
VA0110009460363AM0700X
KYPA2883363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYPA2883OtherKY STATE LICENSE