Provider Demographics
NPI:1609315746
Name:DAWES, TRACY ANN (NP)
Entity Type:Individual
Prefix:
First Name:TRACY ANN
Middle Name:
Last Name:DAWES
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11827 GREENBRIER LN
Mailing Address - Street 2:
Mailing Address - City:GRAND TERRACE
Mailing Address - State:CA
Mailing Address - Zip Code:92313-8342
Mailing Address - Country:US
Mailing Address - Phone:610-858-7145
Mailing Address - Fax:
Practice Address - Street 1:380 W 3RD ST
Practice Address - Street 2:
Practice Address - City:PERRIS
Practice Address - State:CA
Practice Address - Zip Code:92570-2006
Practice Address - Country:US
Practice Address - Phone:951-777-8225
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-22
Last Update Date:2020-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95006106363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily