Provider Demographics
NPI:1679537112
Name:RODENBERG, NANCY IRENE
Entity type:Individual
Prefix:MRS
First Name:NANCY
Middle Name:IRENE
Last Name:RODENBERG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 JEFFERSON BARRACKS RD
Mailing Address - Street 2:11F10-JB
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63125-4181
Mailing Address - Country:US
Mailing Address - Phone:314-894-5770
Mailing Address - Fax:
Practice Address - Street 1:1 JEFFERSON BARRACKS RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63125-4181
Practice Address - Country:US
Practice Address - Phone:314-894-5770
Practice Address - Fax:314-894-5775
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO097588363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health