Provider Demographics
NPI:1588853816
Name:POWELL, TRACEY EARNETTE (DNP)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:EARNETTE
Last Name:POWELL
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1135 3RD ST
Mailing Address - Street 2:
Mailing Address - City:MONTEREY
Mailing Address - State:CA
Mailing Address - Zip Code:93940-3333
Mailing Address - Country:US
Mailing Address - Phone:614-565-8939
Mailing Address - Fax:
Practice Address - Street 1:473 CABRILLO ST # B422
Practice Address - Street 2:
Practice Address - City:MONTEREY
Practice Address - State:CA
Practice Address - Zip Code:93944-3201
Practice Address - Country:US
Practice Address - Phone:831-242-4328
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-23
Last Update Date:2019-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN284714363LP0808X, 364SP0808X
OHRN284714APRNCNP10013286500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes286500000XHospitalsMilitary Hospital
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
1588853816OtherNPI #