Provider Demographics
NPI:1528358405
Name:TRACEY, LUANN MARIE (FNP)
Entity Type:Individual
Prefix:
First Name:LUANN
Middle Name:MARIE
Last Name:TRACEY
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 N NILES AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-1924
Mailing Address - Country:US
Mailing Address - Phone:574-647-1610
Mailing Address - Fax:574-237-6069
Practice Address - Street 1:1708 HIGH ST
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46613-2633
Practice Address - Country:US
Practice Address - Phone:574-647-1400
Practice Address - Fax:574-647-5128
Is Sole Proprietor?:No
Enumeration Date:2011-04-13
Last Update Date:2016-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71003603A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000714838OtherANTHEM
IN000000789433OtherANTHEM
IN000000714843OtherANTHEM
IN201024030Medicaid
IN201024030Medicaid