Provider Demographics
NPI:1124397799
Name:TRACEY, PATRICIA MARIE (APRN)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:MARIE
Last Name:TRACEY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 FOX MEADOW LN
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06107-1215
Mailing Address - Country:US
Mailing Address - Phone:860-233-4009
Mailing Address - Fax:
Practice Address - Street 1:263 FARMINGTON AVE
Practice Address - Street 2:GENERAL MEDICINE
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06030-0001
Practice Address - Country:US
Practice Address - Phone:860-679-4477
Practice Address - Fax:860-679-1025
Is Sole Proprietor?:No
Enumeration Date:2011-12-27
Last Update Date:2012-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT004879363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1124977799Medicaid