Provider Demographics
NPI:1639622285
Name:HOLBERT, TRACIE ANN (FNP)
Entity Type:Individual
Prefix:MISS
First Name:TRACIE
Middle Name:ANN
Last Name:HOLBERT
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 SCHOOL ST
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:IL
Mailing Address - Zip Code:62016-1436
Mailing Address - Country:US
Mailing Address - Phone:217-942-6946
Mailing Address - Fax:217-942-3785
Practice Address - Street 1:800 SCHOOL ST
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:IL
Practice Address - Zip Code:62016-1436
Practice Address - Country:US
Practice Address - Phone:217-942-6946
Practice Address - Fax:217-942-3785
Is Sole Proprietor?:No
Enumeration Date:2016-08-01
Last Update Date:2019-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209014645363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily