Provider Demographics
NPI:1760463665
Name:ANTONACCI, REBECCA A (RD, CDE)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:A
Last Name:ANTONACCI
Suffix:
Gender:F
Credentials:RD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 19640
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62794-9640
Mailing Address - Country:US
Mailing Address - Phone:217-545-3848
Mailing Address - Fax:217-545-4912
Practice Address - Street 1:415 N 9TH ST
Practice Address - Street 2:STE 6W162
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-5303
Practice Address - Country:US
Practice Address - Phone:217-545-3848
Practice Address - Fax:217-545-4912
Is Sole Proprietor?:No
Enumeration Date:2005-11-08
Last Update Date:2010-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164002929133V00000X
IL164-002929133NN1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILR00074Medicare PIN