Provider Demographics
NPI:1649412149
Name:DANLEY, TRACY JOEL (IDC)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:JOEL
Last Name:DANLEY
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 EDISON DR
Mailing Address - Street 2:
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06340-2480
Mailing Address - Country:US
Mailing Address - Phone:803-554-3762
Mailing Address - Fax:
Practice Address - Street 1:USS GREENVILLE # SSN772
Practice Address - Street 2:
Practice Address - City:FPO
Practice Address - State:AP
Practice Address - Zip Code:96666-2428
Practice Address - Country:US
Practice Address - Phone:207-451-3903
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-30
Last Update Date:2009-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman