Provider Demographics
NPI:1063677557
Name:ZOLLAR, TRACEY LYNN (APNP)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:LYNN
Last Name:ZOLLAR
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1630 COMMANCHE AVE
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54313-6089
Mailing Address - Country:US
Mailing Address - Phone:920-430-4700
Mailing Address - Fax:
Practice Address - Street 1:1630 COMMANCHE AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54313-6089
Practice Address - Country:US
Practice Address - Phone:920-430-4700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-23
Last Update Date:2014-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3443-33363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI36084800Medicaid
WI075100081Medicare Oscar/Certification
WI072250041Medicare Oscar/Certification
WI36084800Medicaid
WIWI1097011Medicare Oscar/Certification
WI004107225Medicare Oscar/Certification