Provider Demographics
NPI:1578527107
Name:ACKLIN, TRACI BOYD (MD)
Entity Type:Individual
Prefix:DR
First Name:TRACI
Middle Name:BOYD
Last Name:ACKLIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 6TH AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MONTGOMERY
Mailing Address - State:WV
Mailing Address - Zip Code:25136-2116
Mailing Address - Country:US
Mailing Address - Phone:304-442-7427
Mailing Address - Fax:304-442-0212
Practice Address - Street 1:401 6TH AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:MONTGOMERY
Practice Address - State:WV
Practice Address - Zip Code:25136-2116
Practice Address - Country:US
Practice Address - Phone:304-442-7427
Practice Address - Fax:304-442-0212
Is Sole Proprietor?:No
Enumeration Date:2006-04-12
Last Update Date:2020-06-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WV20405208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1802460000Medicaid