Provider Demographics
NPI:1518030378
Name:FOWLER, TRACEY LYNN (CRNP)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:LYNN
Last Name:FOWLER
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:TRACEY
Other - Middle Name:LYNN
Other - Last Name:WEBB
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:26 N PINE ST
Mailing Address - Street 2:
Mailing Address - City:PORT ALLEGANY
Mailing Address - State:PA
Mailing Address - Zip Code:16743-1344
Mailing Address - Country:US
Mailing Address - Phone:716-307-3714
Mailing Address - Fax:
Practice Address - Street 1:110 CAMPUS DR
Practice Address - Street 2:
Practice Address - City:BRADFORD
Practice Address - State:PA
Practice Address - Zip Code:16701-1982
Practice Address - Country:US
Practice Address - Phone:814-362-6535
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2016-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP009428363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health