Provider Demographics
NPI:1003881244
Name:RIECKENBERG, DEANNE C (APRN)
Entity Type:Individual
Prefix:MRS
First Name:DEANNE
Middle Name:C
Last Name:RIECKENBERG
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:MISS
Other - First Name:DEANNE
Other - Middle Name:C
Other - Last Name:PFIEFFER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CFNP
Mailing Address - Street 1:215 S BURNS AVE
Mailing Address - Street 2:SPARTA MEDICAL OFFICE
Mailing Address - City:SPARTA
Mailing Address - State:IL
Mailing Address - Zip Code:62286
Mailing Address - Country:US
Mailing Address - Phone:618-443-4889
Mailing Address - Fax:
Practice Address - Street 1:215 S BURNS AVE
Practice Address - Street 2:SPARTA MEDICAL OFFICE
Practice Address - City:SPARTA
Practice Address - State:IL
Practice Address - Zip Code:62286
Practice Address - Country:US
Practice Address - Phone:618-443-4889
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2020-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209005645363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL041-315519OtherILLINOIS LICENSE
2005004617OtherANCC CERTIFICATION NUMBER