Provider Demographics
NPI:1063461713
Name:ACHENBACH, TRACEY L (CRNA)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:L
Last Name:ACHENBACH
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:TRACEY
Other - Middle Name:L
Other - Last Name:JAMES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 288
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35804-0288
Mailing Address - Country:US
Mailing Address - Phone:256-880-6711
Mailing Address - Fax:256-880-6712
Practice Address - Street 1:721 MADISON ST SE
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35801-4408
Practice Address - Country:US
Practice Address - Phone:256-880-6711
Practice Address - Fax:256-880-6712
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-105829367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51531739OtherBLUE SHIELD
AL51002179OtherBLUE SHIELD
AL051556509Medicaid
AL051531739Medicaid
AL051556509Medicaid
AL051531739Medicaid
AL51531739OtherBLUE SHIELD