Provider Demographics
NPI:1932692852
Name:LOUCKS, REBECCA (RN)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:LOUCKS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:L
Other - Last Name:BLEDSOE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:4241 HIGHWAY 14 W
Mailing Address - Street 2:
Mailing Address - City:CHRISTOPHER
Mailing Address - State:IL
Mailing Address - Zip Code:62822-1037
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1564 S WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:DU QUOIN
Practice Address - State:IL
Practice Address - Zip Code:62832-3849
Practice Address - Country:US
Practice Address - Phone:618-542-8702
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-14
Last Update Date:2018-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041276610163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse