Provider Demographics
NPI:1043417132
Name:WILKERSON, TRACEY LYNN (NP-C)
Entity Type:Individual
Prefix:MRS
First Name:TRACEY
Middle Name:LYNN
Last Name:WILKERSON
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:TRACEY
Other - Middle Name:LYNN
Other - Last Name:KINCANNON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:1 GUTHRIE SQ
Mailing Address - Street 2:
Mailing Address - City:SAYRE
Mailing Address - State:PA
Mailing Address - Zip Code:18840-1625
Mailing Address - Country:US
Mailing Address - Phone:570-888-5858
Mailing Address - Fax:570-887-6822
Practice Address - Street 1:1 GUTHRIE SQ
Practice Address - Street 2:
Practice Address - City:SAYRE
Practice Address - State:PA
Practice Address - Zip Code:18840-1625
Practice Address - Country:US
Practice Address - Phone:570-888-5858
Practice Address - Fax:570-887-6822
Is Sole Proprietor?:No
Enumeration Date:2007-07-02
Last Update Date:2021-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF309789363LA2200X
MI4704217231363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP00753676OtherRRMEDICARE
MI1043417132Medicaid
12065154OtherCAQH