Provider Demographics
NPI:1134465743
Name:RAIFE, TRACEE SHANAE (ANP)
Entity Type:Individual
Prefix:MRS
First Name:TRACEE
Middle Name:SHANAE
Last Name:RAIFE
Suffix:
Gender:F
Credentials:ANP
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 60352
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63160-0352
Mailing Address - Country:US
Mailing Address - Phone:314-747-5361
Mailing Address - Fax:314-747-5357
Practice Address - Street 1:1255 GRAHAM RD
Practice Address - Street 2:DIV IM PALLIATIVE MED
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63031-8014
Practice Address - Country:US
Practice Address - Phone:314-747-5361
Practice Address - Fax:314-747-5357
Is Sole Proprietor?:No
Enumeration Date:2012-12-31
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012042578363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO420041755Medicaid