Provider Demographics
NPI:1407821549
Name:CLAY, TRACEY D (FNP-BC)
Entity Type:Individual
Prefix:MS
First Name:TRACEY
Middle Name:D
Last Name:CLAY
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:TRACEY
Other - Middle Name:D
Other - Last Name:DORSEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3430 LAKEVIEW PKWY
Mailing Address - Street 2:
Mailing Address - City:ROWLETT
Mailing Address - State:TX
Mailing Address - Zip Code:75088-3367
Mailing Address - Country:US
Mailing Address - Phone:972-475-2597
Mailing Address - Fax:469-728-7352
Practice Address - Street 1:3430 LAKEVIEW PKWY
Practice Address - Street 2:
Practice Address - City:ROWLETT
Practice Address - State:TX
Practice Address - Zip Code:75088-3367
Practice Address - Country:US
Practice Address - Phone:972-515-8700
Practice Address - Fax:469-728-7352
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2014-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024164004363LF0000X
FL1161262363LF0000X
TX786261363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010159792Medicaid
TXTXB142457Medicare PIN
006880S33Medicare ID - Type Unspecified
VA010159792Medicaid
P04209Medicare UPIN
TXTXB142461Medicare PIN