Provider Demographics
NPI:1609805704
Name:EDWARDS, TRACY JOY (FNP)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:JOY
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4200 CONNECTICUT AVE NW BLDG 44
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20008-1122
Mailing Address - Country:US
Mailing Address - Phone:202-274-6434
Mailing Address - Fax:
Practice Address - Street 1:4200 CONNECTICUT AVE NW BLDG 44
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20008-1122
Practice Address - Country:US
Practice Address - Phone:202-274-6434
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-01
Last Update Date:2011-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCRN963123207RG0100X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q67067Medicare UPIN
019211M65Medicare ID - Type Unspecified