Provider Demographics
NPI:1386336790
Name:BALTHAZORE, RACHAEL (ACNPC-AG)
Entity type:Individual
Prefix:
First Name:RACHAEL
Middle Name:
Last Name:BALTHAZORE
Suffix:
Gender:F
Credentials:ACNPC-AG
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:676 N SAINT CLAIR ST STE 2140
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-3143
Mailing Address - Country:US
Mailing Address - Phone:312-695-3800
Mailing Address - Fax:312-695-3644
Practice Address - Street 1:676 N SAINT CLAIR ST STE 2140
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-3143
Practice Address - Country:US
Practice Address - Phone:312-695-3800
Practice Address - Fax:312-695-3644
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-24
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041449506363LA2100X
IL209027881363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care