Provider Demographics
NPI:1568879401
Name:BURRELL, TRACI (NP)
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:
Last Name:BURRELL
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 1:10651 E ST
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78419-5130
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10651 E ST
Practice Address - Street 2:ATTENTION MEDICAL STAFF SERVICES OFFICE
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78419-5130
Practice Address - Country:US
Practice Address - Phone:361-961-2273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-11
Last Update Date:2014-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN8995619261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)