Provider Demographics
NPI:1255758579
Name:BAUKNECHT, NICOLE MARIE (PA-C)
Entity type:Individual
Prefix:MISS
First Name:NICOLE
Middle Name:MARIE
Last Name:BAUKNECHT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1660 FEEHANVILLE DR STE 200
Mailing Address - Street 2:
Mailing Address - City:MOUNT PROSPECT
Mailing Address - State:IL
Mailing Address - Zip Code:60056-6036
Mailing Address - Country:US
Mailing Address - Phone:847-823-3185
Mailing Address - Fax:847-823-3318
Practice Address - Street 1:984 WILLOW RD STE H
Practice Address - Street 2:
Practice Address - City:NORTHBROOK
Practice Address - State:IL
Practice Address - Zip Code:60062-6821
Practice Address - Country:US
Practice Address - Phone:888-938-3838
Practice Address - Fax:888-919-1083
Is Sole Proprietor?:No
Enumeration Date:2014-03-25
Last Update Date:2022-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.004867363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant