MEDICARE: TRACI SUMER KNIERIM NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	209028007	IL
2	363LF0000X	Family Nurse Practitioner	209028007	IL

General Provider Information

NPI Number	:	1407630940
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TRACI SUMER KNIERIM NP

Provider Business Mailing Address
First Line	:	420 BROADWAY AVE E
Second Line	:
City	:	MATTOON
State	:	IL
Zip	:	61938-4655
Country	:	US
Telephone Number	:	217-512-1370
Fax Number	:	217-775-0736

Provider Business Practice Location Address
First Line	:	420 BROADWAY AVE E
Second Line	:
City	:	MATTOON
State	:	IL
Zip	:	61938-4655
Country	:	US
Telephone Number	:	217-512-1370
Fax Number	:	217-775-0736

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/24/2023
Last Update Date	:	04/06/2026

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