Healthcare Provider Details

I. General information

NPI: 1336922137
Provider Name (Legal Business Name): TRACEE J WILLIAMS RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2023
Last Update Date: 08/15/2023
Certification Date: 08/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1465 S GRAND BLVD
SAINT LOUIS MO
63104-1003
US

IV. Provider business mailing address

9821 MARK TRL
FAIRVIEW HEIGHTS IL
62208-1612
US

V. Phone/Fax

Practice location:
  • Phone: 314-577-5600
  • Fax:
Mailing address:
  • Phone: 618-219-5730
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number041528275
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number2021005902
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: