Provider Demographics
NPI:1275942245
Name:CUNNINGHAM, TRACEY (CRNP-PMH)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:
Last Name:CUNNINGHAM
Suffix:
Gender:F
Credentials:CRNP-PMH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5132 KEY VIEW WAY
Mailing Address - Street 2:
Mailing Address - City:PERRY HALL
Mailing Address - State:MD
Mailing Address - Zip Code:21128-8938
Mailing Address - Country:US
Mailing Address - Phone:410-919-3503
Mailing Address - Fax:
Practice Address - Street 1:114 S WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21231-1937
Practice Address - Country:US
Practice Address - Phone:410-255-1400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-04
Last Update Date:2014-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR166906363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health