Provider Demographics
NPI:1346630969
Name:WILSON, TRACI
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TRACI
Other - Middle Name:
Other - Last Name:BOEHM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2384 BRANDERMILL BLVD
Mailing Address - Street 2:
Mailing Address - City:GAMBRILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21054-1850
Mailing Address - Country:US
Mailing Address - Phone:443-302-6297
Mailing Address - Fax:443-302-6289
Practice Address - Street 1:2384 BRANDERMILL BLVD
Practice Address - Street 2:
Practice Address - City:GAMBRILLS
Practice Address - State:MD
Practice Address - Zip Code:21054-1850
Practice Address - Country:US
Practice Address - Phone:443-302-6279
Practice Address - Fax:443-302-6289
Is Sole Proprietor?:No
Enumeration Date:2015-02-03
Last Update Date:2015-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDT11798183700000X
CA118732183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician