Provider Demographics
NPI:1720330608
Name:BOGAN, REBEKAH B (FNP)
Entity Type:Individual
Prefix:MS
First Name:REBEKAH
Middle Name:B
Last Name:BOGAN
Suffix:
Gender:F
Credentials:FNP
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 3008
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62902-3008
Mailing Address - Country:US
Mailing Address - Phone:618-457-0450
Mailing Address - Fax:618-734-3566
Practice Address - Street 1:13245 KESSLER RD
Practice Address - Street 2:
Practice Address - City:CAIRO
Practice Address - State:IL
Practice Address - Zip Code:62914-3101
Practice Address - Country:US
Practice Address - Phone:618-734-4400
Practice Address - Fax:618-477-8557
Is Sole Proprietor?:No
Enumeration Date:2012-10-03
Last Update Date:2021-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041407232163W00000X
IL209010690363L00000X
IL277001252363LF0000X
MO2012033119363LF0000X
MO2009015162163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1720330608Medicaid