Basic Information
| Provider Information | |||||||||
| NPI: | 1508258476 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FOSTER | ||||||||
| FirstName: | TRACIE | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 955860 | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631953060 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6364985944 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1441 W BROADWAY | ||||||||
| Address2: | |||||||||
| City: | CENTRALIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 628015613 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6185329050 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2015 | ||||||||
| LastUpdateDate: | 10/19/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 209072853 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.