Provider Demographics
NPI:1518046002
Name:JOHNSON, TRACY LYNN (NP)
Entity Type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:LYNN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6326 CONSTITUTION DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-1518
Mailing Address - Country:US
Mailing Address - Phone:260-515-3275
Mailing Address - Fax:888-803-6843
Practice Address - Street 1:7900 W JEFFERSON BLVD
Practice Address - Street 2:SUITE 304
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-4128
Practice Address - Country:US
Practice Address - Phone:260-435-6200
Practice Address - Fax:260-435-6201
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2017-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71000592A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200246760Medicaid
IN252560LMedicare PIN