Provider Demographics
NPI:1093450728
Name:RENFROE, REBECCA ELIZABETH (CNP)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:ELIZABETH
Last Name:RENFROE
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:702 S TOWER RD
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901-5208
Mailing Address - Country:US
Mailing Address - Phone:270-889-3870
Mailing Address - Fax:
Practice Address - Street 1:405 W JACKSON ST
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-1467
Practice Address - Country:US
Practice Address - Phone:618-549-0721
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-27
Last Update Date:2022-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041466518163WR0006X
IL209.023102363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First Assistant