Provider Demographics
NPI:1033673819
Name:MIRIKI, TRACY-ANN PATRICE
Entity Type:Individual
Prefix:MRS
First Name:TRACY-ANN
Middle Name:PATRICE
Last Name:MIRIKI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8803 WILLOW COVE LN
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33467-1171
Mailing Address - Country:US
Mailing Address - Phone:561-876-1706
Mailing Address - Fax:
Practice Address - Street 1:8803 WILLOW COVE LN
Practice Address - Street 2:
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33467-1171
Practice Address - Country:US
Practice Address - Phone:561-876-1706
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-26
Last Update Date:2019-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11000541363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily