Provider Demographics
NPI:1659096600
Name:BLUE, TRACEY ROSE
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:ROSE
Last Name:BLUE
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 1:5743 DEB DR W
Mailing Address - Street 2:
Mailing Address - City:WEST FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58078-4074
Mailing Address - Country:US
Mailing Address - Phone:701-382-9630
Mailing Address - Fax:
Practice Address - Street 1:5743 DEB DR W
Practice Address - Street 2:
Practice Address - City:WEST FARGO
Practice Address - State:ND
Practice Address - Zip Code:58078-4074
Practice Address - Country:US
Practice Address - Phone:701-382-9630
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-11
Last Update Date:2022-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant