Provider Demographics
NPI:1164054755
Name:GOLL, TRACI (ARNP)
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:
Last Name:GOLL
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 S ILLINOIS AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:MASON CITY
Mailing Address - State:IA
Mailing Address - Zip Code:50401-5489
Mailing Address - Country:US
Mailing Address - Phone:641-428-3041
Mailing Address - Fax:
Practice Address - Street 1:1410 6TH AVE S
Practice Address - Street 2:
Practice Address - City:CLEAR LAKE
Practice Address - State:IA
Practice Address - Zip Code:50428-2606
Practice Address - Country:US
Practice Address - Phone:641-357-2191
Practice Address - Fax:641-357-6020
Is Sole Proprietor?:No
Enumeration Date:2020-02-11
Last Update Date:2022-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA157789363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily