Provider Demographics
NPI:1679910871
Name:KLECK, REBEKAH LYNN (CRNA)
Entity type:Individual
Prefix:
First Name:REBEKAH
Middle Name:LYNN
Last Name:KLECK
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:REBEKAH
Other - Middle Name:LYNN
Other - Last Name:MONTGOMERY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1900 EXETER RD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38138-2954
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6019 WALNUT GROVE RD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120-2113
Practice Address - Country:US
Practice Address - Phone:901-226-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-28
Last Update Date:2015-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR084272163W00000X
TN17683367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ000997Medicaid
TN6030022OtherBCBS TENNESSEE