Provider Demographics
NPI:1245661750
Name:SHANKLIN, TRACI (NP)
Entity type:Individual
Prefix:
First Name:TRACI
Middle Name:
Last Name:SHANKLIN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:TRACI
Other - Middle Name:
Other - Last Name:SHIVERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:1507 BELLEVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60436-2428
Mailing Address - Country:US
Mailing Address - Phone:815-603-5319
Mailing Address - Fax:
Practice Address - Street 1:1890 SILVER CROSS BLVD
Practice Address - Street 2:ST 350
Practice Address - City:NEW LENOX
Practice Address - State:IL
Practice Address - Zip Code:60451-9524
Practice Address - Country:US
Practice Address - Phone:815-717-8737
Practice Address - Fax:815-717-8699
Is Sole Proprietor?:No
Enumeration Date:2013-12-09
Last Update Date:2014-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209010966363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily