Provider Demographics
NPI:1720202369
Name:PENDER, REBECCA SUE (RN)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:SUE
Last Name:PENDER
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 1:1007 230TH ST
Mailing Address - Street 2:
Mailing Address - City:ALEDO
Mailing Address - State:IL
Mailing Address - Zip Code:61231-8533
Mailing Address - Country:US
Mailing Address - Phone:309-582-1116
Mailing Address - Fax:
Practice Address - Street 1:219 E EUCLID AVE
Practice Address - Street 2:
Practice Address - City:MONMOUTH
Practice Address - State:IL
Practice Address - Zip Code:61462-1247
Practice Address - Country:US
Practice Address - Phone:309-734-9461
Practice Address - Fax:309-734-3909
Is Sole Proprietor?:No
Enumeration Date:2007-04-13
Last Update Date:2009-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA077683163W00000X
IL041.246874163WP0808X, 163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
No163WC0400XNursing Service ProvidersRegistered NurseCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL041.246874OtherR N LICENSE
IA077683OtherR N LICENSE
IL370984175OtherBWAY INC FEIN