Provider Demographics
NPI:1942743281
Name:BOOTH, RACHAEL B (APNP)
Entity Type:Individual
Prefix:
First Name:RACHAEL
Middle Name:B
Last Name:BOOTH
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2825 HUNTERS TRL
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:WI
Mailing Address - Zip Code:53901-3429
Mailing Address - Country:US
Mailing Address - Phone:608-742-7161
Mailing Address - Fax:608-745-3990
Practice Address - Street 1:2825 HUNTERS TRL
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:WI
Practice Address - Zip Code:53901-3429
Practice Address - Country:US
Practice Address - Phone:608-742-7161
Practice Address - Fax:608-745-3990
Is Sole Proprietor?:No
Enumeration Date:2016-11-18
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7337-33363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1942743281Medicaid
WI1942743281Medicaid
WIP01789948Medicare PIN