Provider Demographics
NPI:1033732995
Name:TABARES, TRACEE (FNP)
Entity Type:Individual
Prefix:
First Name:TRACEE
Middle Name:
Last Name:TABARES
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 1:702 RUSSELL AVE
Mailing Address - Street 2:
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20877-2606
Mailing Address - Country:US
Mailing Address - Phone:240-595-7659
Mailing Address - Fax:
Practice Address - Street 1:100 S MARKET ST
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21701-5527
Practice Address - Country:US
Practice Address - Phone:301-600-1506
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-26
Last Update Date:2021-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001271471163WP0200X
VA0024180389363L00000X
MDAC003567363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WP0200XNursing Service ProvidersRegistered NursePediatrics