Provider Demographics
NPI:1457668295
Name:SAMBOLIN, TRACI DAWN (NP)
Entity Type:Individual
Prefix:MRS
First Name:TRACI
Middle Name:DAWN
Last Name:SAMBOLIN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MS
Other - First Name:TRACI
Other - Middle Name:DAWN
Other - Last Name:SHEPHERD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1 HOSPITAL DR # CE306
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65212-1000
Mailing Address - Country:US
Mailing Address - Phone:573-882-8863
Mailing Address - Fax:
Practice Address - Street 1:1 HOSPITAL DR # CE306
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65212-3050
Practice Address - Country:US
Practice Address - Phone:573-882-8863
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-31
Last Update Date:2023-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013017560363LF0000X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily