Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 213E00000X | Podiatrist | 213.000402 | IL |
Y | 222Z00000X | Podiatrist | 213.000402 | IL |
N | 224P00000X | Prosthetist | 211.000354 | IL |
NPI | 1396371225 |
---|---|
Provider Name | Breanna Angela Baltrusch |
First Address | Chicago, IL 60611-2991 |
Second Address | Chicago, IL 60614-2730 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 23/03/2020 |
Last Update Date | 23/03/2020 |