Provider Demographics
NPI:1275622888
Name:TRACEY, STEPHANIE (PA)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:TRACEY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 E DEVON AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:ITASCA
Mailing Address - State:IL
Mailing Address - Zip Code:60143-2639
Mailing Address - Country:US
Mailing Address - Phone:864-625-3376
Mailing Address - Fax:
Practice Address - Street 1:550 E DEVON AVE STE 200
Practice Address - Street 2:
Practice Address - City:ITASCA
Practice Address - State:IL
Practice Address - Zip Code:60143-2639
Practice Address - Country:US
Practice Address - Phone:864-625-3376
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2022-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-001077363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant