Provider Demographics
NPI:1962768036
Name:LILJESTROM, TRACEY HARROP
Entity type:Individual
Prefix:
First Name:TRACEY
Middle Name:HARROP
Last Name:LILJESTROM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TRACEY
Other - Middle Name:LYNN
Other - Last Name:HARROP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9000 W WISCONSIN AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-4874
Mailing Address - Country:US
Mailing Address - Phone:414-337-7050
Mailing Address - Fax:414-337-7020
Practice Address - Street 1:9000 W WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-4874
Practice Address - Country:US
Practice Address - Phone:414-337-7050
Practice Address - Fax:414-337-7020
Is Sole Proprietor?:No
Enumeration Date:2012-04-03
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI67663208000000X, 2080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1962768036Medicaid