Healthcare Provider Details

I. General information

NPI: 1891443289
Provider Name (Legal Business Name): RACHAEL DEMATTEI APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: RACHAEL SCHAEFER

II. Dates (important events)

Enumeration Date: 03/15/2022
Last Update Date: 10/17/2023
Certification Date: 10/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

321 REGENCY PARK STE 100
O FALLON IL
62269-1887
US

IV. Provider business mailing address

PO BOX 25228
DECATUR IL
62525-5228
US

V. Phone/Fax

Practice location:
  • Phone: 618-416-7970
  • Fax: 618-416-7971
Mailing address:
  • Phone: 217-329-3232
  • Fax: 217-233-1670

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041495134
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number2017003138
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209027937
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: