Provider Demographics
NPI:1629821087
Name:WITTMANN, REBECCA JANE (RN)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:JANE
Last Name:WITTMANN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 HARVEST CT
Mailing Address - Street 2:
Mailing Address - City:GLEN CARBON
Mailing Address - State:IL
Mailing Address - Zip Code:62034-1622
Mailing Address - Country:US
Mailing Address - Phone:618-616-0713
Mailing Address - Fax:
Practice Address - Street 1:1 SAINT ELIZABETH BLVD
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-1099
Practice Address - Country:US
Practice Address - Phone:618-234-2120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-08
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041393938163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse