Basic Information
Provider Information | |||||||||
NPI: | 1760463665 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ANTONACCI | ||||||||
FirstName: | REBECCA | ||||||||
MiddleName: | A | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | RD, CDE | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 19640 | ||||||||
Address2: |   | ||||||||
City: | SPRINGFIELD | ||||||||
State: | IL | ||||||||
PostalCode: | 627949640 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2175453848 | ||||||||
FaxNumber: | 2175454912 | ||||||||
Practice Location | |||||||||
Address1: | 415 N 9TH ST | ||||||||
Address2: | STE 6W162 | ||||||||
City: | SPRINGFIELD | ||||||||
State: | IL | ||||||||
PostalCode: | 627025303 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2175453848 | ||||||||
FaxNumber: | 2175454912 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/08/2005 | ||||||||
LastUpdateDate: | 03/18/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 164002929 | IL | N |   | Dietary & Nutritional Service Providers | Dietitian, Registered |   | 133NN1002X | 164-002929 | IL | Y |   | Dietary & Nutritional Service Providers | Nutritionist | Nutrition, Education |
No ID Information.