Provider Demographics
NPI:1437625597
Name:CORN, TRACIE (FNP-C)
Entity Type:Individual
Prefix:
First Name:TRACIE
Middle Name:
Last Name:CORN
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RUSHVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46173-1116
Mailing Address - Country:US
Mailing Address - Phone:765-932-4111
Mailing Address - Fax:765-932-7062
Practice Address - Street 1:1 MEMORIAL SQ STE 2200
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:IN
Practice Address - Zip Code:46140-1378
Practice Address - Country:US
Practice Address - Phone:317-462-6662
Practice Address - Fax:317-468-6275
Is Sole Proprietor?:No
Enumeration Date:2018-10-16
Last Update Date:2021-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71008477A363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN363L00000XOtherNURSE PRACTITIONER