Provider Demographics
NPI:1679881676
Name:O'CONNOR, RACHEL M (NP)
Entity type:Individual
Prefix:
First Name:RACHEL
Middle Name:M
Last Name:O'CONNOR
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:RACHEL
Other - Middle Name:M
Other - Last Name:AXSOM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:PO BOX 1149
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47402-1149
Mailing Address - Country:US
Mailing Address - Phone:812-353-3087
Mailing Address - Fax:
Practice Address - Street 1:1302 S ROGERS ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-4752
Practice Address - Country:US
Practice Address - Phone:812-676-4144
Practice Address - Fax:812-339-8344
Is Sole Proprietor?:No
Enumeration Date:2010-09-24
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71003406A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200998290Medicaid
IN200998290Medicaid