Provider Demographics
NPI:1699022848
Name:BAXTER, TRACEYANN R (NP)
Entity Type:Individual
Prefix:MRS
First Name:TRACEYANN
Middle Name:R
Last Name:BAXTER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:473 PARK PL APT 1L
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11238-4623
Mailing Address - Country:US
Mailing Address - Phone:718-230-3868
Mailing Address - Fax:
Practice Address - Street 1:473 PARK PL APT 1L
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11238-4623
Practice Address - Country:US
Practice Address - Phone:718-230-3868
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-07
Last Update Date:2012-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF420968-1363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health