Provider Demographics
NPI:1952660300
Name:ARNOLD, TRACY (APNP)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:ARNOLD
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28843 LINN ST
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:IL
Mailing Address - Zip Code:62801-5817
Mailing Address - Country:US
Mailing Address - Phone:618-322-5069
Mailing Address - Fax:618-918-2565
Practice Address - Street 1:1011 W BROADWAY
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:IL
Practice Address - Zip Code:62801-5309
Practice Address - Country:US
Practice Address - Phone:618-918-2566
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-04
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209009665363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209009665OtherAPN LICENSE
IL209009665OtherAPN LICENSE