Provider Demographics
NPI:1942209622
Name:ODISHOO, TRACEY ANN (CNP)
Entity Type:Individual
Prefix:MS
First Name:TRACEY
Middle Name:ANN
Last Name:ODISHOO
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:MS
Other - First Name:TRACEY
Other - Middle Name:ANN
Other - Last Name:ODISHOO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NURSE PRACTITIONER
Mailing Address - Street 1:3701 DOTY RD
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:IL
Mailing Address - Zip Code:60098-7509
Mailing Address - Country:US
Mailing Address - Phone:815-338-6600
Mailing Address - Fax:815-206-1086
Practice Address - Street 1:3701 DOTY RD
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:IL
Practice Address - Zip Code:60098
Practice Address - Country:US
Practice Address - Phone:815-338-6600
Practice Address - Fax:815-206-1086
Is Sole Proprietor?:No
Enumeration Date:2005-07-15
Last Update Date:2022-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209003621363L00000X, 363LF0000X, 363LP0808X
IL277001103363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209003621OtherSTATE LICENSE
IL962341OtherMEDICARE GROUP PTAN
ILP00401136Medicare PIN
ILK11840Medicare PIN
ILK11841Medicare PIN