Provider Demographics
NPI:1740598507
Name:BRINK, TRACEY LYNN (RN)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:LYNN
Last Name:BRINK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:TRACEY
Other - Middle Name:LYNN
Other - Last Name:WATKINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 909
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40201-0909
Mailing Address - Country:US
Mailing Address - Phone:502-588-0329
Mailing Address - Fax:502-588-0326
Practice Address - Street 1:571 S FLOYD ST
Practice Address - Street 2:SUITE 342
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-3818
Practice Address - Country:US
Practice Address - Phone:502-852-8470
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-15
Last Update Date:2015-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH363594163W00000X
KY3006556363LN0000X
CT006114363LN0000X
CT126171163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201040490Medicaid