=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619456472
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TRACIE LYNN EILERMAN FNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/11/2018
-----------------------------------------------------
Last Update Date | 01/03/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5213 GODFREY RD STE 110
-----------------------------------------------------
City | GODFREY
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62035-2510
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-619-3330
-----------------------------------------------------
Fax | 618-619-3390
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5213 GODFREY RD STE 110
-----------------------------------------------------
City | GODFREY
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62035-2510
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-619-3330
-----------------------------------------------------
Fax | 618-619-3390
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163WC0200X
-----------------------------------------------------
Taxonomy Name | Critical Care Medicine Registered Nurse
-----------------------------------------------------
License Number | 2002007983
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 163WC0200X
-----------------------------------------------------
Taxonomy Name | Critical Care Medicine Registered Nurse
-----------------------------------------------------
License Number | 041360734
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 2018012811
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 209017718
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------