Basic Information
| Provider Information | |||||||||
| NPI: | 1942857222 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PACKER | ||||||||
| FirstName: | TRACY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 E FAIRMAN AVE | ||||||||
| Address2: | |||||||||
| City: | WATSEKA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 609701644 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2176216360 | ||||||||
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| Practice Location | |||||||||
| Address1: | 200 E FAIRMAN AVE | ||||||||
| Address2: | |||||||||
| City: | WATSEKA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 609701644 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8154325841 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2019 | ||||||||
| LastUpdateDate: | 10/13/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 209018658 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.