Healthcare Provider Details

I. General information

NPI: 1649877416
Provider Name (Legal Business Name): RACHEL MAURINE CAUDLE NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2020
Last Update Date: 04/12/2021
Certification Date: 04/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2222 E STATE ST STE 209
ROCKFORD IL
61104-1572
US

IV. Provider business mailing address

2222 E STATE ST STE 209
ROCKFORD IL
61104-1572
US

V. Phone/Fax

Practice location:
  • Phone: 815-988-8500
  • Fax:
Mailing address:
  • Phone: 815-988-8500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209022114
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: