Provider Demographics
NPI:1063261345
Name:IVERSEN, TRACY ANN (PMHNP)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:ANN
Last Name:IVERSEN
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:724 E CARROLL ST
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:IL
Mailing Address - Zip Code:61455-2454
Mailing Address - Country:US
Mailing Address - Phone:309-313-4801
Mailing Address - Fax:
Practice Address - Street 1:210 W WALNUT ST
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:IL
Practice Address - Zip Code:61520-2444
Practice Address - Country:US
Practice Address - Phone:309-647-0201
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-17
Last Update Date:2024-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209029712363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health