Provider Demographics
NPI:1578139150
Name:CONRAD, TRACY LYNN (DOM)
Entity Type:Individual
Prefix:DR
First Name:TRACY
Middle Name:LYNN
Last Name:CONRAD
Suffix:
Gender:F
Credentials:DOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:644 PASEO DE PERALTA
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87501-1955
Mailing Address - Country:US
Mailing Address - Phone:505-984-8830
Mailing Address - Fax:505-982-1225
Practice Address - Street 1:644 PASEO DE PERALTA
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87501-1955
Practice Address - Country:US
Practice Address - Phone:505-984-8830
Practice Address - Fax:505-982-1225
Is Sole Proprietor?:No
Enumeration Date:2021-06-03
Last Update Date:2021-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM549171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist