Provider Demographics
NPI:1114180015
Name:RHEAUME, TRACEY JO (PNP)
Entity Type:Individual
Prefix:MRS
First Name:TRACEY
Middle Name:JO
Last Name:RHEAUME
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:750 E ADAMS ST
Mailing Address - Street 2:DEPT OF PEDIATRICS
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13210-2342
Mailing Address - Country:US
Mailing Address - Phone:315-464-2089
Mailing Address - Fax:315-464-6398
Practice Address - Street 1:725 IRVING AVENUE SUITE 112
Practice Address - Street 2:CENTER FOR NEURODEVELOPMEMTL PEDIATRICS CROUSE POB
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-1624
Practice Address - Country:US
Practice Address - Phone:315-464-2089
Practice Address - Fax:315-464-6398
Is Sole Proprietor?:No
Enumeration Date:2008-07-10
Last Update Date:2008-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF381083-1363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics