Provider Demographics
NPI:1407407885
Name:CASWELL, TRACY ADELE (APRN)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:ADELE
Last Name:CASWELL
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5370 CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:IL
Mailing Address - Zip Code:62881-7202
Mailing Address - Country:US
Mailing Address - Phone:618-367-6145
Mailing Address - Fax:
Practice Address - Street 1:1201 RICKER RD
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:IL
Practice Address - Zip Code:62881-4263
Practice Address - Country:US
Practice Address - Phone:618-548-3194
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-26
Last Update Date:2022-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.020124041.288784363LF0000X
IL209.0201240363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily