Healthcare Provider Details

I. General information

NPI: 1992414304
Provider Name (Legal Business Name): NATASHA CAROL RHODES AGNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2022
Last Update Date: 03/13/2024
Certification Date: 03/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4121 VETERANS MEMORIAL DR
MOUNT VERNON IL
62864-6262
US

IV. Provider business mailing address

502 E ASH ST
OKAWVILLE IL
62271-2253
US

V. Phone/Fax

Practice location:
  • Phone: 618-242-3778
  • Fax:
Mailing address:
  • Phone: 618-967-7936
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number2022043467
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number2022043467
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209026552
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: