Provider Demographics
NPI:1396044871
Name:STEPHENSON, TRACY P (RN)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:P
Last Name:STEPHENSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1448 HILLCREST DR
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62246-2759
Mailing Address - Country:US
Mailing Address - Phone:618-322-1973
Mailing Address - Fax:
Practice Address - Street 1:1448 HILLCREST DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:IL
Practice Address - Zip Code:62246-2759
Practice Address - Country:US
Practice Address - Phone:618-322-1973
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-23
Last Update Date:2011-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041354818163W00000X
NVRN65372163W00000X
MO2007019359163W00000X
CA767596163W00000X
CORN192436163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA767596OtherRN
IL041354818OtherRN
MO2007019359OtherRN
CORN192436OtherRN
NVRN65372OtherRN