Provider Demographics
NPI:1952609786
Name:COPE, REBECCA L (RD)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:L
Last Name:COPE
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:L
Other - Last Name:WYNSTRA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
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:217-545-5117
Mailing Address - Fax:217-545-4912
Practice Address - Street 1:415 N 9TH ST
Practice Address - Street 2:SUITE 6W100
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-5303
Practice Address - Country:US
Practice Address - Phone:217-545-5117
Practice Address - Fax:217-545-4912
Is Sole Proprietor?:No
Enumeration Date:2011-03-02
Last Update Date:2011-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164-005426133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL256510094Medicare PIN