Healthcare Provider Details

I. General information

NPI: 1336537919
Provider Name (Legal Business Name): REBECCA LYN CARPENTER ANP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2015
Last Update Date: 02/16/2026
Certification Date: 02/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4550 MEMORIAL DR STE 280
BELLEVILLE IL
62226-5372
US

IV. Provider business mailing address

PO BOX 959203
SAINT LOUIS MO
63195-9203
US

V. Phone/Fax

Practice location:
  • Phone: 618-767-3235
  • Fax: 618-624-4982
Mailing address:
  • Phone: 618-767-3235
  • Fax: 618-624-4982

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209020059
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number2014041453
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: