Provider Demographics
NPI:1396369138
Name:ROBERTS, TRACY ANN (DNP, NP-C)
Entity Type:Individual
Prefix:DR
First Name:TRACY
Middle Name:ANN
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:DNP, NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4740 N PENNGROVE WAY STE 100
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-7446
Mailing Address - Country:US
Mailing Address - Phone:208-938-3663
Mailing Address - Fax:
Practice Address - Street 1:4740 N PENNGROVE WAY STE 100
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83646-7446
Practice Address - Country:US
Practice Address - Phone:208-938-3663
Practice Address - Fax:208-938-3664
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-06
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID51644363LF0000X
ID65132363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily