Basic Information
Provider Information | |||||||||
NPI: | 1285385674 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CORBO | ||||||||
FirstName: | RACHEL | ||||||||
MiddleName: | ANN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | FNP-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4108 N MORRIS BLVD | ||||||||
Address2: |   | ||||||||
City: | SHOREWOOD | ||||||||
State: | WI | ||||||||
PostalCode: | 532111839 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9492448192 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | W129N7055 NORTHFIELD DR | ||||||||
Address2: |   | ||||||||
City: | MENOMONEE FALLS | ||||||||
State: | WI | ||||||||
PostalCode: | 530510538 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2622535400 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/17/2022 | ||||||||
LastUpdateDate: | 10/16/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/16/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 11890 | WI | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   | 163WE0003X | 240853-30 | WI | N |   | Nursing Service Providers | Registered Nurse | Emergency |
No ID Information.