Provider Demographics
NPI:1508340498
Name:TRACY, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:TRACY
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 1:720 62ND STREET OCEAN
Mailing Address - Street 2:
Mailing Address - City:MARATHON
Mailing Address - State:FL
Mailing Address - Zip Code:33050-2739
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3000 41ST STREET OCEAN
Practice Address - Street 2:
Practice Address - City:MARATHON
Practice Address - State:FL
Practice Address - Zip Code:33050-2373
Practice Address - Country:US
Practice Address - Phone:305-434-7660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-18
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2730022163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health