Healthcare Provider Details

I. General information

NPI: 1619456472
Provider Name (Legal Business Name): TRACIE LYNN EILERMAN FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2018
Last Update Date: 01/03/2025
Certification Date: 01/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5213 GODFREY RD STE 110
GODFREY IL
62035-2510
US

IV. Provider business mailing address

5213 GODFREY RD STE 110
GODFREY IL
62035-2510
US

V. Phone/Fax

Practice location:
  • Phone: 618-619-3330
  • Fax: 618-619-3390
Mailing address:
  • Phone: 618-619-3330
  • Fax: 618-619-3390

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number2002007983
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number041360734
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2018012811
License Number StateMO
# 4
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209017718
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: