MEDICARE: DR. BRECK BAKER PMHNP -BC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	101.0136156	VT
2	363LF0000X	Family Nurse Practitioner	RN 256580	MA
3	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	APRN11001264	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1619411279
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRECK BAKER PMHNP -BC

Provider Business Mailing Address
First Line	:	302 LINDEN RD
Second Line	:
City	:	ST AUGUSTINE
State	:	FL
Zip	:	32086-6742
Country	:	US
Telephone Number	:	802-255-8788
Fax Number	:	802-200-0493

Provider Business Practice Location Address
First Line	:	720 N FRANKLIN ST STE 401
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60654-7212
Country	:	US
Telephone Number	:	877-442-0042
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/15/2016
Last Update Date	:	03/17/2026

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