Provider Demographics
NPI:1295484012
Name:WHITEHEAD, REBECKA ANNE (LPN)
Entity type:Individual
Prefix:
First Name:REBECKA
Middle Name:ANNE
Last Name:WHITEHEAD
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5135 ROCKBERRY RD
Mailing Address - Street 2:
Mailing Address - City:LOVES PARK
Mailing Address - State:IL
Mailing Address - Zip Code:61111-3389
Mailing Address - Country:US
Mailing Address - Phone:608-295-3662
Mailing Address - Fax:
Practice Address - Street 1:5135 ROCKBERRY RD
Practice Address - Street 2:
Practice Address - City:LOVES PARK
Practice Address - State:IL
Practice Address - Zip Code:61111-3389
Practice Address - Country:US
Practice Address - Phone:608-295-3662
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-20
Last Update Date:2022-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL043.109145164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL043.109145OtherLICENSED PRACTICAL NURSE LICENSE