Healthcare Provider Details

I. General information

NPI: 1760463665
Provider Name (Legal Business Name): REBECCA A ANTONACCI RD, CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2005
Last Update Date: 03/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 N 9TH ST STE 6W162
SPRINGFIELD IL
62702-5303
US

IV. Provider business mailing address

PO BOX 19640
SPRINGFIELD IL
62794-9640
US

V. Phone/Fax

Practice location:
  • Phone: 217-545-3848
  • Fax: 217-545-4912
Mailing address:
  • Phone: 217-545-3848
  • Fax: 217-545-4912

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number164002929
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number164-002929
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: