Provider Demographics
NPI:1699390179
Name:PRUDEN, TRACEY ANN (FNP-C)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:ANN
Last Name:PRUDEN
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2501 E 800 N
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IN
Mailing Address - Zip Code:46733-9453
Mailing Address - Country:US
Mailing Address - Phone:260-701-5100
Mailing Address - Fax:
Practice Address - Street 1:205 TOWER DR
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:IN
Practice Address - Zip Code:46772-9362
Practice Address - Country:US
Practice Address - Phone:260-926-6163
Practice Address - Fax:833-854-9653
Is Sole Proprietor?:No
Enumeration Date:2020-06-10
Last Update Date:2022-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28202009A163W00000X
IN71010245A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse