Provider Demographics
NPI:1003493958
Name:OMOROGIEVA, TRACY O
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:O
Last Name:OMOROGIEVA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17901 GOVERNORS HWY STE 206
Mailing Address - Street 2:
Mailing Address - City:HOMEWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60430-1146
Mailing Address - Country:US
Mailing Address - Phone:708-960-0390
Mailing Address - Fax:
Practice Address - Street 1:17901 GOVERNORS HWY STE 206
Practice Address - Street 2:
Practice Address - City:HOMEWOOD
Practice Address - State:IL
Practice Address - Zip Code:60430-1146
Practice Address - Country:US
Practice Address - Phone:708-960-4280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-26
Last Update Date:2021-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.022270363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily