Provider Demographics
NPI:1891321220
Name:RACK, PETRA P
Entity Type:Individual
Prefix:
First Name:PETRA
Middle Name:P
Last Name:RACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6149 N BROADWAY ST APT 406
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60660-1670
Mailing Address - Country:US
Mailing Address - Phone:262-893-8001
Mailing Address - Fax:
Practice Address - Street 1:6149 N BROADWAY ST APT 406
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60660-1670
Practice Address - Country:US
Practice Address - Phone:262-893-8001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-17
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered