Provider Demographics
NPI:1437402237
Name:OBRIEN, TRACY FAIRBANKS (CNM)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:FAIRBANKS
Last Name:OBRIEN
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:860 ARCADE ST
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55106-3852
Mailing Address - Country:US
Mailing Address - Phone:651-772-9757
Mailing Address - Fax:651-602-7517
Practice Address - Street 1:860 ARCADE ST
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55106-3852
Practice Address - Country:US
Practice Address - Phone:651-772-9757
Practice Address - Fax:651-602-7517
Is Sole Proprietor?:No
Enumeration Date:2012-10-18
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR 161513-5367A00000X
OR10013604367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife