Provider Demographics
NPI:1477695849
Name:LARUE, TRACIE
Entity Type:Individual
Prefix:
First Name:TRACIE
Middle Name:
Last Name:LARUE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:265 ELLINGTON RD
Mailing Address - Street 2:
Mailing Address - City:EAST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06108-1176
Mailing Address - Country:US
Mailing Address - Phone:860-569-8800
Mailing Address - Fax:860-291-2788
Practice Address - Street 1:265 ELLINGTON RD
Practice Address - Street 2:
Practice Address - City:EAST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06108-1176
Practice Address - Country:US
Practice Address - Phone:860-569-8800
Practice Address - Fax:860-291-2788
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2011-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTE57063363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
1477695849OtherNPI
CT500002248Medicare UPIN