Provider Demographics
NPI:1700447604
Name:PHROMMALA, REBECCA ANNE
Entity type:Individual
Prefix:MRS
First Name:REBECCA
Middle Name:ANNE
Last Name:PHROMMALA
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 1:131 BENTONVILLE LN
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30134-6300
Mailing Address - Country:US
Mailing Address - Phone:678-200-3281
Mailing Address - Fax:
Practice Address - Street 1:501 REDMOND RD NW
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-1415
Practice Address - Country:US
Practice Address - Phone:706-291-0291
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-22
Last Update Date:2019-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL367H00000X
GA367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant