Healthcare Provider Details

I. General information

NPI: 1689447500
Provider Name (Legal Business Name): JUSTIN LOUIE CAMACHO APRN, CNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2023
Last Update Date: 08/15/2025
Certification Date: 08/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

251 E HURON ST STE 5-704
CHICAGO IL
60611-2908
US

IV. Provider business mailing address

251 E HURON ST STE 5-704
CHICAGO IL
60611-2908
US

V. Phone/Fax

Practice location:
  • Phone: 312-695-0061
  • Fax: 312-926-8341
Mailing address:
  • Phone: 312-695-0061
  • Fax: 312-926-8341

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number28240550A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code363LC0200X
TaxonomyCritical Care Medicine Nurse Practitioner
License Number71014667A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209028094
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: