Provider Demographics
NPI:1336683275
Name:PETROCELLI, TRACY N
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:N
Last Name:PETROCELLI
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 1:8505 TECHNOLOGY FOREST PL
Mailing Address - Street 2:#1002
Mailing Address - City:THE WOODLANDS
Mailing Address - State:TX
Mailing Address - Zip Code:77381-1000
Mailing Address - Country:US
Mailing Address - Phone:936-701-0899
Mailing Address - Fax:936-417-1011
Practice Address - Street 1:8505 TECHNOLOGY FOREST PL
Practice Address - Street 2:#1002
Practice Address - City:THE WOODLANDS
Practice Address - State:TX
Practice Address - Zip Code:77381-1000
Practice Address - Country:US
Practice Address - Phone:936-701-0899
Practice Address - Fax:936-417-1011
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-12
Last Update Date:2016-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies