Provider Demographics
NPI:1083166433
Name:CARPENTER, TRACEY ANN (NP-C)
Entity Type:Individual
Prefix:MRS
First Name:TRACEY
Middle Name:ANN
Last Name:CARPENTER
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:MISS
Other - First Name:TRACEY
Other - Middle Name:ANN
Other - Last Name:BROADWATER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:622 DARTMOUTH CREST DR
Mailing Address - Street 2:
Mailing Address - City:WILDWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63011-5433
Mailing Address - Country:US
Mailing Address - Phone:636-284-0263
Mailing Address - Fax:
Practice Address - Street 1:232 S WOODS MILL RD STE 400
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-3467
Practice Address - Country:US
Practice Address - Phone:314-878-2888
Practice Address - Fax:314-576-8167
Is Sole Proprietor?:No
Enumeration Date:2016-11-02
Last Update Date:2016-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016023933363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily