Provider Demographics
NPI:1124561212
Name:PARRISH, TRACIE NUSCA
Entity Type:Individual
Prefix:
First Name:TRACIE
Middle Name:NUSCA
Last Name:PARRISH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:152 FRONT ST
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32082-3058
Mailing Address - Country:US
Mailing Address - Phone:352-283-3717
Mailing Address - Fax:
Practice Address - Street 1:152 FRONT ST
Practice Address - Street 2:
Practice Address - City:PONTE VEDRA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32082-3058
Practice Address - Country:US
Practice Address - Phone:904-285-3634
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-22
Last Update Date:2022-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9316468363LF0000X
CA95005171363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily