Provider Demographics
NPI:1619308475
Name:RICKETTSFACEY, TRICIA
Entity Type:Individual
Prefix:
First Name:TRICIA
Middle Name:
Last Name:RICKETTSFACEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 SPRING RIDGE CT
Mailing Address - Street 2:
Mailing Address - City:DANBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06811-3084
Mailing Address - Country:US
Mailing Address - Phone:347-538-4542
Mailing Address - Fax:
Practice Address - Street 1:100 RESERVE RD STE A4
Practice Address - Street 2:
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06810-5267
Practice Address - Country:US
Practice Address - Phone:203-794-1979
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-04
Last Update Date:2023-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1118207R00000X
CT11183363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine