Healthcare Provider Details

I. General information

NPI: 1306760061
Provider Name (Legal Business Name): OLIVIA BRYN RACETTE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2026
Last Update Date: 08/06/2026
Certification Date: 08/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5440 FARGO AVE
SKOKIE IL
60077-3210
US

IV. Provider business mailing address

5440 FARGO AVE
SKOKIE IL
60077-3210
US

V. Phone/Fax

Practice location:
  • Phone: 847-383-9510
  • Fax:
Mailing address:
  • Phone: 847-383-9510
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: