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General NPI Number Information
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NPI Number | 1952337131
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Entity Type | Individual
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Provider Name | TRACEY DAWN KINIGAKIS MD
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Gender | Female
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Dates
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Enumeration Date | 06/23/2006
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Last Update Date | 08/28/2009
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Provider Practice Location Address
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Address Line | 1495 NORTHROCK CT
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City | ROCKFORD
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State | IL
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Zip | 61103-1233
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Country | US
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Telephone | 815-618-8116
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Fax |
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Provider Business Mailing Address
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Address Line | 10168 SUSAN CT
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City | ROSCOE
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State | IL
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Zip | 61073-9309
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Country | US
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Telephone | 815-623-1354
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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 | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 036095213
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License Number State | IL
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