=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386711489
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALEXIS BAINE BABY CPNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/30/2006
-----------------------------------------------------
Last Update Date | 09/15/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 225 E CHICAGO AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60611-2991
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-227-3581
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 187 RIDGE AVE
-----------------------------------------------------
City | WINNETKA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60093-3838
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-573-7993
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Nurse Practitioner
-----------------------------------------------------
License Number | 209-006136
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------