Provider Demographics
NPI:1154501807
Name:MARSH, TRACEY DAWN (RN, CPNP)
Entity Type:Individual
Prefix:MRS
First Name:TRACEY
Middle Name:DAWN
Last Name:MARSH
Suffix:
Gender:F
Credentials:RN, CPNP
Other - Prefix:MS
Other - First Name:TRACEY
Other - Middle Name:DAWN
Other - Last Name:MACKLING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7777 FOREST LN
Mailing Address - Street 2:STE B-246
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75230-2571
Mailing Address - Country:US
Mailing Address - Phone:972-566-7730
Mailing Address - Fax:972-566-7437
Practice Address - Street 1:7777 FOREST LN
Practice Address - Street 2:STE B-246
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75230-2571
Practice Address - Country:US
Practice Address - Phone:972-566-7730
Practice Address - Fax:972-566-7437
Is Sole Proprietor?:No
Enumeration Date:2007-11-10
Last Update Date:2016-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX666076363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8L21331Medicare PIN