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General NPI Number Information
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NPI Number | 1063261345
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Entity Type | Individual
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Provider Name | TRACY ANN IVERSEN PMHNP
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Gender | Female
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Dates
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Enumeration Date | 05/17/2024
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Last Update Date | 05/20/2024
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Provider Practice Location Address
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Address Line | 210 W WALNUT ST
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City | CANTON
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State | IL
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Zip | 61520-2444
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Country | US
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Telephone | 309-647-0201
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Fax |
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Provider Business Mailing Address
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Address Line | 724 E CARROLL ST
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City | MACOMB
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State | IL
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Zip | 61455-2454
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Country | US
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Telephone | 309-313-4801
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | 209029712
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License Number State | IL
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