Healthcare Provider Details

I. General information

NPI: 1629871447
Provider Name (Legal Business Name): TRACEY FERGUSON PMHNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2025
Last Update Date: 08/03/2026
Certification Date: 08/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1707 E MAIN ST STE 8
OLNEY IL
62450-3156
US

IV. Provider business mailing address

7860 E WESTLAKE DR
ROBINSON IL
62454-4898
US

V. Phone/Fax

Practice location:
  • Phone: 812-618-8573
  • Fax: 618-388-3016
Mailing address:
  • Phone: 812-618-8573
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number309.024347
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number209.031329
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: