Provider Demographics
NPI:1407630940
Name:KNIERIM, TRACI SUMER (NP)
Entity type:Individual
Prefix:
First Name:TRACI
Middle Name:SUMER
Last Name:KNIERIM
Suffix:
Gender:
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3115 VILLAGE OFFICE PL
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61822-7673
Mailing Address - Country:US
Mailing Address - Phone:217-531-4101
Mailing Address - Fax:217-954-9290
Practice Address - Street 1:3115 VILLAGE OFFICE PL
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61822-7673
Practice Address - Country:US
Practice Address - Phone:217-531-4101
Practice Address - Fax:217-954-9290
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-24
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209028007363LF0000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily