Provider Demographics
NPI:1407407315
Name:RIETBERG, REBECCA JO (NP)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:JO
Last Name:RIETBERG
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:JO
Other - Last Name:VANDENBERGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:4100 EMBASSY DR SE STE 400
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-2416
Mailing Address - Country:US
Mailing Address - Phone:616-975-1845
Mailing Address - Fax:
Practice Address - Street 1:1108 W STATE ST
Practice Address - Street 2:
Practice Address - City:HASTINGS
Practice Address - State:MI
Practice Address - Zip Code:49058-9711
Practice Address - Country:US
Practice Address - Phone:269-945-3451
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-23
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704304050363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner