Provider Demographics
NPI:1124872924
Name:PEACHEY, TRACEY SAMANTHA (FNP)
Entity type:Individual
Prefix:
First Name:TRACEY
Middle Name:SAMANTHA
Last Name:PEACHEY
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 N WALL ST STE 102
Mailing Address - Street 2:
Mailing Address - City:KANKAKEE
Mailing Address - State:IL
Mailing Address - Zip Code:60901-2934
Mailing Address - Country:US
Mailing Address - Phone:815-928-5090
Mailing Address - Fax:
Practice Address - Street 1:401 N WALL ST STE 102
Practice Address - Street 2:
Practice Address - City:KANKAKEE
Practice Address - State:IL
Practice Address - Zip Code:60901-2934
Practice Address - Country:US
Practice Address - Phone:815-928-5090
Practice Address - Fax:815-928-5079
Is Sole Proprietor?:No
Enumeration Date:2024-04-16
Last Update Date:2024-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209030161363L00000X
IL041353756163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse