Basic Information
| Provider Information | |||||||||
| NPI: | 1437707825 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MONTESA | ||||||||
| FirstName: | TRACY | ||||||||
| MiddleName: | LALUMA | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2220 W MAYPOLE AVE UNIT 302 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606122342 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6305506594 | ||||||||
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| Practice Location | |||||||||
| Address1: | 836 W WELLINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606575147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7739751600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2019 | ||||||||
| LastUpdateDate: | 08/28/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 364SA2100X | 209019180 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Acute Care |
ID Information
| ID | Type | State | Issuer | Description | 00000000000000000000 | 01 | N/A | OTHER |