Healthcare Provider Details

I. General information

NPI: 1740101740
Provider Name (Legal Business Name): ANASTASIA RAQUEL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2026
Last Update Date: 07/24/2026
Certification Date: 07/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1135 SKOKIE BLVD
NORTHBROOK IL
60062-4118
US

IV. Provider business mailing address

1124 S 4TH AVE
LIBERTYVILLE IL
60048-3719
US

V. Phone/Fax

Practice location:
  • Phone: 847-441-5600
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: