Provider Demographics
NPI:1083156376
Name:CABLE, TRACEY (FNP)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:
Last Name:CABLE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5841 S MARYLAND AVE STE E-500
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60637-1443
Mailing Address - Country:US
Mailing Address - Phone:773-702-3316
Mailing Address - Fax:773-702-4187
Practice Address - Street 1:5841 S MARYLAND AVE STE E-500
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60637
Practice Address - Country:US
Practice Address - Phone:773-702-3316
Practice Address - Fax:773-702-4187
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-17
Last Update Date:2018-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28189189A363LF0000X
IL209017316363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200760Medicare PIN