Provider Demographics
NPI:1245381060
Name:FARWELL, TRACY NICOLE (BA DC)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:NICOLE
Last Name:FARWELL
Suffix:
Gender:F
Credentials:BA DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5750 RUDDELL RD SE
Mailing Address - Street 2:STE B
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98503
Mailing Address - Country:US
Mailing Address - Phone:360-412-8286
Mailing Address - Fax:360-412-7403
Practice Address - Street 1:5750 RUDDELL RD SE
Practice Address - Street 2:STE B
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503
Practice Address - Country:US
Practice Address - Phone:360-412-8286
Practice Address - Fax:360-412-7403
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00034299111N00000X
CADC28887111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
U97681Medicare UPIN
WAGAB40277Medicare ID - Type Unspecified