Provider Demographics
NPI:1417908526
Name:MULLINS, TRACY E (NP)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:E
Last Name:MULLINS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:E
Other - Last Name:RITCHIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11141 PARKVIEW PLAZA DR STE 325
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1714
Practice Address - Country:US
Practice Address - Phone:260-425-5400
Practice Address - Fax:260-425-5417
Is Sole Proprietor?:No
Enumeration Date:2006-05-13
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71002116A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000530707OtherANTHEM BC/BS
IN200821790Medicaid
OH2734376Medicaid
IN136140VMedicare PIN
IN200821790Medicaid
OHDG2339Medicare PIN
INP00339873Medicare PIN