Provider Demographics
NPI:1053042762
Name:BELCHER, TRACIE DYANN (MSN,NP-C)
Entity Type:Individual
Prefix:
First Name:TRACIE
Middle Name:DYANN
Last Name:BELCHER
Suffix:
Gender:F
Credentials:MSN,NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3245 HEALTH DR STE 100
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-1380
Mailing Address - Country:US
Mailing Address - Phone:574-647-2129
Mailing Address - Fax:
Practice Address - Street 1:2222 RIETH BLVD STE 100
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46526-5869
Practice Address - Country:US
Practice Address - Phone:574-875-1200
Practice Address - Fax:574-875-0362
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-22
Last Update Date:2023-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INF06220033363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300068000Medicaid