Provider Demographics
NPI:1598735185
Name:TRACY, TERRI SUSANN (CRNA)
Entity Type:Individual
Prefix:
First Name:TERRI
Middle Name:SUSANN
Last Name:TRACY
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 388
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:KS
Mailing Address - Zip Code:67114-0388
Mailing Address - Country:US
Mailing Address - Phone:316-281-3700
Mailing Address - Fax:316-282-4322
Practice Address - Street 1:1905 W 32ND ST
Practice Address - Street 2:STE 201
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804
Practice Address - Country:US
Practice Address - Phone:417-206-7900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2011-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO120842367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered