Provider Demographics
NPI:1053630103
Name:TRACY, MAURIE DOLORES (ANP-BC)
Entity Type:Individual
Prefix:MS
First Name:MAURIE
Middle Name:DOLORES
Last Name:TRACY
Suffix:
Gender:F
Credentials:ANP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6435 CHIPPEWA ST
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63109-2104
Mailing Address - Country:US
Mailing Address - Phone:314-353-1870
Mailing Address - Fax:314-353-0315
Practice Address - Street 1:6435 CHIPPEWA ST
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63109-2104
Practice Address - Country:US
Practice Address - Phone:314-353-1870
Practice Address - Fax:314-353-0315
Is Sole Proprietor?:No
Enumeration Date:2010-05-27
Last Update Date:2010-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010012804363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health