Provider Demographics
NPI:1720590615
Name:WALKER, TRACEY RENEE
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:RENEE
Last Name:WALKER
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:PO BOX 296
Mailing Address - Street 2:
Mailing Address - City:BEULAH
Mailing Address - State:CO
Mailing Address - Zip Code:81023-0296
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1303 FORTINO BLVD STE C
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-2032
Practice Address - Country:US
Practice Address - Phone:719-582-1010
Practice Address - Fax:719-582-1010
Is Sole Proprietor?:No
Enumeration Date:2017-10-31
Last Update Date:2017-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COACU0001916171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1417489519Medicaid