Provider Demographics
NPI:1053320697
Name:BRILLANTE, RAQUEL TADALAN (CNP)
Entity Type:Individual
Prefix:
First Name:RAQUEL
Middle Name:TADALAN
Last Name:BRILLANTE
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 ORLAND SQUARE DR
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60462-6548
Mailing Address - Country:US
Mailing Address - Phone:708-226-9055
Mailing Address - Fax:
Practice Address - Street 1:60 ORLAND SQUARE DR
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60462-6548
Practice Address - Country:US
Practice Address - Phone:708-226-9055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209000444363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209-000444OtherCNP LICENSE #
IL209000444Medicaid
IL309000581OtherCONTROLLED SUBSTANCE
IL309000581OtherCONTROLLED SUBSTANCE
IL209000444Medicaid