Healthcare Provider Details

I. General information

NPI: 1740041755
Provider Name (Legal Business Name): RACHEL LEE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/17/2024
Last Update Date: 10/18/2024
Certification Date: 10/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 NE GLEN OAK AVE STE 201
PEORIA IL
61603-3112
US

IV. Provider business mailing address

420 NE GLEN OAK AVE STE 201
PEORIA IL
61603-3112
US

V. Phone/Fax

Practice location:
  • Phone: 309-655-2343
  • Fax: 309-655-3948
Mailing address:
  • Phone: 309-655-2343
  • Fax: 309-655-3948

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085010576
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: