Provider Demographics
NPI:1497169056
Name:POWELL, TRACY
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:POWELL
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 1:5211 HIGHWAY 110
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:MN
Mailing Address - Zip Code:55705-1522
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5211 HIGHWAY 110
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:MN
Practice Address - Zip Code:55705-1522
Practice Address - Country:US
Practice Address - Phone:218-229-4246
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-11
Last Update Date:2014-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR173832-6163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management