Provider Demographics
NPI:1639779523
Name:HANSEN, TRACIE LYN (BS)
Entity Type:Individual
Prefix:
First Name:TRACIE
Middle Name:LYN
Last Name:HANSEN
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:TRACIE
Other - Middle Name:LYN
Other - Last Name:BURRUP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:611 WILSON AVE STE 5
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-5046
Mailing Address - Country:US
Mailing Address - Phone:208-915-8448
Mailing Address - Fax:
Practice Address - Street 1:560 FAIRWAY DR
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-2012
Practice Address - Country:US
Practice Address - Phone:208-242-6669
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-29
Last Update Date:2023-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCPSS055175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer SpecialistGroup - Multi-Specialty