Provider Demographics
NPI:1558702332
Name:TRACEY, KATHLEEN REBECCA (CRNP)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:REBECCA
Last Name:TRACEY
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:REBECCA
Other - Last Name:FEARON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:161 JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:MA
Mailing Address - Zip Code:01852-2103
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:161 JACKSON ST
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01852-2103
Practice Address - Country:US
Practice Address - Phone:978-937-9700
Practice Address - Fax:978-221-6728
Is Sole Proprietor?:No
Enumeration Date:2013-07-09
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR187571363LP0200X
MARN2305437363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics