Healthcare Provider Details

I. General information

NPI: 1649543042
Provider Name (Legal Business Name): TRACI LEIGH BLAKE DNP,ACNPC-AG, CRNFA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TRACI L GOODELL

II. Dates (important events)

Enumeration Date: 02/15/2012
Last Update Date: 05/01/2025
Certification Date: 05/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8201 E RIVERSIDE BLVD
ROCKFORD IL
61114-2300
US

IV. Provider business mailing address

2563 W CREEDY RD # 1
BELOIT WI
53511-8707
US

V. Phone/Fax

Practice location:
  • Phone: 815-971-7000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License Number041336983
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number209032163
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: