Basic Information
| Provider Information | |||||||||
| NPI: | 1952609786 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COPE | ||||||||
| FirstName: | REBECCA | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | R.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WYNSTRA | ||||||||
| OtherFirstName: | REBECCA | ||||||||
| OtherMiddleName: | L | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | RD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 19640 | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 627949640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2175455117 | ||||||||
| FaxNumber: | 2175454912 | ||||||||
| Practice Location | |||||||||
| Address1: | 415 N 9TH ST | ||||||||
| Address2: | SUITE 6W100 | ||||||||
| City: | SPRINGFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 627025303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2175455117 | ||||||||
| FaxNumber: | 2175454912 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2011 | ||||||||
| LastUpdateDate: | 03/29/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 164-005426 | IL | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.