Healthcare Provider Details

I. General information

NPI: 1407630940
Provider Name (Legal Business Name): TRACI SUMER KNIERIM NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2023
Last Update Date: 12/12/2025
Certification Date: 12/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3115 VILLAGE OFFICE PL
CHAMPAIGN IL
61822-7673
US

IV. Provider business mailing address

3115 VILLAGE OFFICE PL
CHAMPAIGN IL
61822-7673
US

V. Phone/Fax

Practice location:
  • Phone: 217-531-4101
  • Fax: 217-954-9290
Mailing address:
  • Phone: 217-531-4101
  • Fax: 217-954-9290

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number209028007
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209028007
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: