Healthcare Provider Details

I. General information

NPI: 1720330608
Provider Name (Legal Business Name): REBEKAH B BOGAN FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2012
Last Update Date: 02/25/2021
Certification Date: 02/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13245 KESSLER RD
CAIRO IL
62914-3101
US

IV. Provider business mailing address

PO BOX 3008
CARBONDALE IL
62902-3008
US

V. Phone/Fax

Practice location:
  • Phone: 618-734-4400
  • Fax: 618-477-8557
Mailing address:
  • Phone: 618-457-0450
  • Fax: 618-734-3566

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041407232
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209010690
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number277001252
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2012033119
License Number StateMO
# 5
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number2009015162
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: