Provider Demographics
NPI:1730649583
Name:MUSSER, TRACY LYNN (BA)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:LYNN
Last Name:MUSSER
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3265 INTERTECH DR
Mailing Address - Street 2:
Mailing Address - City:ANGOLA
Mailing Address - State:IN
Mailing Address - Zip Code:46703-7325
Mailing Address - Country:US
Mailing Address - Phone:260-318-5511
Mailing Address - Fax:
Practice Address - Street 1:3265 INTERTECH DR
Practice Address - Street 2:
Practice Address - City:ANGOLA
Practice Address - State:IN
Practice Address - Zip Code:46703-7325
Practice Address - Country:US
Practice Address - Phone:260-318-5511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-20
Last Update Date:2019-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN171M00000XOtherWRAPAROUND