Provider Demographics
NPI:1942574769
Name:CLISBY, TRACIE E
Entity Type:Individual
Prefix:DR
First Name:TRACIE
Middle Name:E
Last Name:CLISBY
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:PO BOX 5367
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60680-5367
Mailing Address - Country:US
Mailing Address - Phone:773-340-1307
Mailing Address - Fax:773-232-8195
Practice Address - Street 1:5841 S MARYLAND AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60637-1443
Practice Address - Country:US
Practice Address - Phone:888-824-0200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-24
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL277002085363LF0000X
IL277.002085363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily