Provider Demographics
NPI:1598981193
Name:ANTLE, TRACEY ANN (CNM)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:ANN
Last Name:ANTLE
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1305 6TH ST
Mailing Address - Street 2:
Mailing Address - City:PERU
Mailing Address - State:IL
Mailing Address - Zip Code:61354-2759
Mailing Address - Country:US
Mailing Address - Phone:815-780-5029
Mailing Address - Fax:815-223-4095
Practice Address - Street 1:920 WEST ST
Practice Address - Street 2:BLDG B
Practice Address - City:PERU
Practice Address - State:IL
Practice Address - Zip Code:61354-2763
Practice Address - Country:US
Practice Address - Phone:815-223-2944
Practice Address - Fax:815-223-4095
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2011-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-0043370367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL819300031Medicare PIN