Provider Demographics
NPI:1487828885
Name:WILSON, TRACEY (CRNP)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 64442
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-4442
Mailing Address - Country:US
Mailing Address - Phone:410-328-8141
Mailing Address - Fax:
Practice Address - Street 1:29 S GREENE ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1504
Practice Address - Country:US
Practice Address - Phone:410-328-8141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-16
Last Update Date:2015-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR115362363LA2100X, 363LC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LC0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCritical Care Medicine
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD419033500Medicaid
MDS062-0375OtherBLUE SHIELD REGIONAL
MD960542-01 & 02OtherBLUE CROSS/BLUE SHIELD
MD960542-01 & 02OtherBLUE CROSS/BLUE SHIELD
MD419033500Medicaid
MD172381ZCEAMedicare PIN