Provider Demographics
NPI:1336322007
Name:HARRIS, TRACI (NP)
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:
Last Name:HARRIS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 S MADISON ST
Mailing Address - Street 2:
Mailing Address - City:OSWEGO
Mailing Address - State:IL
Mailing Address - Zip Code:60543-9056
Mailing Address - Country:US
Mailing Address - Phone:630-631-4855
Mailing Address - Fax:
Practice Address - Street 1:1325 REMINGTON RD STE A
Practice Address - Street 2:
Practice Address - City:SCHAUMBURG
Practice Address - State:IL
Practice Address - Zip Code:60173-4815
Practice Address - Country:US
Practice Address - Phone:773-572-8399
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-17
Last Update Date:2019-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI198169163W00000X
IL20900440363LA2200X
IL209004400363LF0000X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL2556004Medicare PIN