Provider Demographics
NPI:1699263731
Name:SHADLEY, TRACY (FNP)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:SHADLEY
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 1:4215 NEWBURG RD
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108-6479
Mailing Address - Country:US
Mailing Address - Phone:815-988-8500
Mailing Address - Fax:815-977-5956
Practice Address - Street 1:7220 GREAT HILL RD
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60012-1637
Practice Address - Country:US
Practice Address - Phone:847-999-8777
Practice Address - Fax:815-893-4534
Is Sole Proprietor?:No
Enumeration Date:2018-04-24
Last Update Date:2024-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL277.001865363LF0000X, 364SP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily