Provider Demographics
NPI:1578276051
Name:SHELLHORN, TRACY
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:SHELLHORN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:808 GREGORY WAY
Mailing Address - Street 2:
Mailing Address - City:WINNEBAGO
Mailing Address - State:IL
Mailing Address - Zip Code:61088-9595
Mailing Address - Country:US
Mailing Address - Phone:815-988-0635
Mailing Address - Fax:
Practice Address - Street 1:535 ROXBURY RD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-5076
Practice Address - Country:US
Practice Address - Phone:815-397-7212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-30
Last Update Date:2022-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209026644363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care