Provider Demographics
NPI:1649543042
Name:BLAKE, TRACI LEIGH (DNP,ACNPC-AG, CRNFA)
Entity type:Individual
Prefix:
First Name:TRACI
Middle Name:LEIGH
Last Name:BLAKE
Suffix:
Gender:
Credentials:DNP,ACNPC-AG, CRNFA
Other - Prefix:
Other - First Name:TRACI
Other - Middle Name:L
Other - Last Name:GOODELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2563 W CREEDY RD # 1
Mailing Address - Street 2:
Mailing Address - City:BELOIT
Mailing Address - State:WI
Mailing Address - Zip Code:53511-8707
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8201 E RIVERSIDE BLVD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61114-2300
Practice Address - Country:US
Practice Address - Phone:815-971-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-15
Last Update Date:2025-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041336983163WR0006X
IL209032163363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First Assistant