Individual
MS. TRACEY ANN ODISHOO
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
C.N.P.
Contact information
Practice address
3701 DOTY RD, WOODSTOCK, IL 60098
(815) 338-6600
(815) 206-1086
Mailing address
3701 DOTY RD, WOODSTOCK, IL 60098-7509
(815) 338-6600
(815) 206-1086
Taxonomy
Speciality
Code
Description
License number
State
363L00000X
Nurse Practitioner
209003621
IL
363L00000X
Nurse Practitioner
Primary
277001103
IL
363LF0000X
Family Nurse Practitioner
209003621
IL
363LP0808X
Psychiatric/Mental Health Nurse Practitioner
209003621
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
209003621
STATE LICENSE
IL
01
—
962341
MEDICARE GROUP PTAN
IL
Enumeration date
07/15/2005
Last updated
12/28/2022
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