Healthcare Provider Details

I. General information

NPI: 1578197513
Provider Name (Legal Business Name): TRACIE R KELLY APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/28/2020
Last Update Date: 05/22/2025
Certification Date: 05/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 E 12TH ST
MENDOTA IL
61342-9216
US

IV. Provider business mailing address

110 8TH ST
MENDOTA IL
61342-1846
US

V. Phone/Fax

Practice location:
  • Phone: 815-539-7461
  • Fax:
Mailing address:
  • Phone: 815-878-8847
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number277.004233
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: