Provider Demographics
NPI:1013265248
Name:RODENBERG, DEANNA L (NP)
Entity Type:Individual
Prefix:MRS
First Name:DEANNA
Middle Name:L
Last Name:RODENBERG
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4550 MEMORIAL DR
Mailing Address - Street 2:STE. 340
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62226-5372
Mailing Address - Country:US
Mailing Address - Phone:618-257-6200
Mailing Address - Fax:618-257-6679
Practice Address - Street 1:4550 MEMORIAL DR
Practice Address - Street 2:STE. 340
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62226-5372
Practice Address - Country:US
Practice Address - Phone:618-257-6200
Practice Address - Fax:618-257-6679
Is Sole Proprietor?:No
Enumeration Date:2012-08-20
Last Update Date:2014-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012025805363LF0000X
IL041404382163W00000X
IL209009887363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209009887OtherAPN
IL041404382OtherRN
IL209009887OtherAPN
IL209009887OtherAPN