Provider Demographics
NPI:1417578980
Name:HEISE, RACHEL NICOLE (CRNA)
Entity Type:Individual
Prefix:
First Name:RACHEL
Middle Name:NICOLE
Last Name:HEISE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3611 W MONTROSE AVE UNIT 303
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-1030
Mailing Address - Country:US
Mailing Address - Phone:920-450-5903
Mailing Address - Fax:
Practice Address - Street 1:5145 N CALIFORNIA AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-3661
Practice Address - Country:US
Practice Address - Phone:773-293-5486
Practice Address - Fax:773-989-1639
Is Sole Proprietor?:No
Enumeration Date:2020-05-06
Last Update Date:2022-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI171244163W00000X
IL041450662163W00000X
IL209021413367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse