Healthcare Provider Details

I. General information

NPI: 1265610489
Provider Name (Legal Business Name): TRACI A GERNER O.T.R./L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/11/2008
Last Update Date: 02/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1915 BISON LN
JOHNSBURG IL
60051-5243
US

IV. Provider business mailing address

1915 BISON LN
JOHNSBURG IL
60051-5243
US

V. Phone/Fax

Practice location:
  • Phone: 815-578-1715
  • Fax:
Mailing address:
  • Phone: 815-578-1715
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: