Provider Demographics
NPI:1700211497
Name:BOOTHE, TRACI LYNN (APRN, FNP-BC, ONC)
Entity Type:Individual
Prefix:MS
First Name:TRACI
Middle Name:LYNN
Last Name:BOOTHE
Suffix:
Gender:F
Credentials:APRN, FNP-BC, ONC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 RIVERGRASS DR
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-7223
Mailing Address - Country:US
Mailing Address - Phone:337-241-4385
Mailing Address - Fax:
Practice Address - Street 1:1214 COOLIDGE BLVD
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70503-2621
Practice Address - Country:US
Practice Address - Phone:337-289-7497
Practice Address - Fax:337-289-8670
Is Sole Proprietor?:No
Enumeration Date:2013-09-12
Last Update Date:2013-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP07531363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily