Healthcare Provider Details

I. General information

NPI: 1366290306
Provider Name (Legal Business Name): KRISTA RAE ZAMORA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2024
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1890 SILVER CROSS BLVD, PAVILION A SUITE
NEW LENOX IL
60451
US

IV. Provider business mailing address

1890 SILVER CROSS BLVD, PAVILION A - SUITE 455 SUITE 455
NEW LENOX IL
60451
US

V. Phone/Fax

Practice location:
  • Phone: 815-300-5915
  • Fax: 773-834-0629
Mailing address:
  • Phone: 815-399-5915
  • Fax: 773-834-0629

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: