Provider Demographics
NPI:1073297636
Name:THOMAS, TRACI MICHELLE (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:MICHELLE
Last Name:THOMAS
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10940 LAWRENCE RD
Mailing Address - Street 2:
Mailing Address - City:SUMNER
Mailing Address - State:IL
Mailing Address - Zip Code:62466-4915
Mailing Address - Country:US
Mailing Address - Phone:618-936-2064
Mailing Address - Fax:
Practice Address - Street 1:10940 LAWRENCE RD
Practice Address - Street 2:
Practice Address - City:SUMNER
Practice Address - State:IL
Practice Address - Zip Code:62466-4915
Practice Address - Country:US
Practice Address - Phone:618-936-2064
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-14
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209027549363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health