Provider Demographics
NPI:1578290540
Name:TRACEY, CAROLYN (FNP)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:
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 1:554 BROOK RD
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:MA
Mailing Address - Zip Code:02186-2824
Mailing Address - Country:US
Mailing Address - Phone:978-602-5328
Mailing Address - Fax:
Practice Address - Street 1:87 N MAIN ST
Practice Address - Street 2:
Practice Address - City:LEOMINSTER
Practice Address - State:MA
Practice Address - Zip Code:01453-5507
Practice Address - Country:US
Practice Address - Phone:978-534-8701
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-01
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2348466363L00000X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse