Provider Demographics
NPI:1093287187
Name:CARACCI, TAWNIE C (APN, FNP)
Entity Type:Individual
Prefix:
First Name:TAWNIE
Middle Name:C
Last Name:CARACCI
Suffix:
Gender:F
Credentials:APN, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 10097
Mailing Address - Street 2:
Mailing Address - City:CASA GRANDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85130-0020
Mailing Address - Country:US
Mailing Address - Phone:520-836-3446
Mailing Address - Fax:
Practice Address - Street 1:1437 W. AUTO DRIVE
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85284
Practice Address - Country:US
Practice Address - Phone:023-622-9836
Practice Address - Fax:855-889-8024
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-30
Last Update Date:2019-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ227917363L00000X
IL041383554163W00000X
IL209.018703363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ566542Medicaid