Provider Demographics
NPI:1417292905
Name:WHITNEY, TRACEY LYNN (CRNA)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:LYNN
Last Name:WHITNEY
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:TRACEY
Other - Middle Name:LYNN
Other - Last Name:OAKLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:5052 N CLINTON ST
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-5822
Mailing Address - Country:US
Mailing Address - Phone:260-484-8551
Mailing Address - Fax:260-482-5060
Practice Address - Street 1:5050 N CLINTON ST
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-5886
Practice Address - Country:US
Practice Address - Phone:260-484-8551
Practice Address - Fax:260-482-5060
Is Sole Proprietor?:No
Enumeration Date:2012-12-10
Last Update Date:2018-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28141092A367500000X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201131480Medicaid