Provider Demographics
NPI:1598747578
Name:HEESE, TRACI MAE (APRN)
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:MAE
Last Name:HEESE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:126 MISSOURI AVE
Mailing Address - Street 2:GLWACH (ATTN: SHEILA HAM)
Mailing Address - City:FORT LEONARD WOOD
Mailing Address - State:MO
Mailing Address - Zip Code:65473-8952
Mailing Address - Country:US
Mailing Address - Phone:573-596-0417
Mailing Address - Fax:
Practice Address - Street 1:126 MISSOURI AVE
Practice Address - Street 2:GLWACH (ATTN: SHEILA HAM)
Practice Address - City:FORT LEONARD WOOD
Practice Address - State:MO
Practice Address - Zip Code:65473-8952
Practice Address - Country:US
Practice Address - Phone:573-596-0417
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-16
Last Update Date:2009-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE110497363LF0000X
SDCR000714367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily