Provider Demographics
NPI:1578129987
Name:PALMER, TRACY A (APRN)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:A
Last Name:PALMER
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:PO BOX 78866
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53278-8866
Mailing Address - Country:US
Mailing Address - Phone:779-696-7150
Mailing Address - Fax:
Practice Address - Street 1:1700 HENRY LUCKOW LN
Practice Address - Street 2:
Practice Address - City:BELVIDERE
Practice Address - State:IL
Practice Address - Zip Code:61008-1702
Practice Address - Country:US
Practice Address - Phone:779-696-8650
Practice Address - Fax:815-544-4691
Is Sole Proprietor?:No
Enumeration Date:2019-05-13
Last Update Date:2021-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041271286163W00000X
IL209019441363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse