Provider Demographics
NPI:1396776498
Name:BLACKBURN, TRACEE A (PA-C)
Entity type:Individual
Prefix:MRS
First Name:TRACEE
Middle Name:A
Last Name:BLACKBURN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:TRACEE
Other - Middle Name:ANGELA
Other - Last Name:DOUSE-DEAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1460 NORTH HALSTED STREET
Mailing Address - Street 2:SUITE 505
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60642
Mailing Address - Country:US
Mailing Address - Phone:312-266-6462
Mailing Address - Fax:312-266-6481
Practice Address - Street 1:1460 NORTH HALSTED STREET
Practice Address - Street 2:SUITE 505
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60642
Practice Address - Country:US
Practice Address - Phone:312-266-6462
Practice Address - Fax:312-266-6481
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2016-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-002507207N00000X, 2080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine