Provider Demographics
NPI:1295226298
Name:FATE, TRACY
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:FATE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16643 W QUAIL RUN RD
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85387-6280
Mailing Address - Country:US
Mailing Address - Phone:623-694-7222
Mailing Address - Fax:
Practice Address - Street 1:15455 W BELL RD
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85374-3411
Practice Address - Country:US
Practice Address - Phone:623-694-7222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-24
Last Update Date:2018-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ15483225700000X
AZMT-15483225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist