Provider Demographics
NPI:1750687208
Name:MYERS, TRACIE KATHRYN (TM)
Entity Type:Individual
Prefix:
First Name:TRACIE
Middle Name:KATHRYN
Last Name:MYERS
Suffix:
Gender:F
Credentials:TM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22976 QUAMBA ST
Mailing Address - Street 2:
Mailing Address - City:BROOK PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55007-4674
Mailing Address - Country:US
Mailing Address - Phone:763-691-3746
Mailing Address - Fax:320-679-7045
Practice Address - Street 1:22976 QUAMBA ST
Practice Address - Street 2:
Practice Address - City:BROOK PARK
Practice Address - State:MN
Practice Address - Zip Code:55007-4674
Practice Address - Country:US
Practice Address - Phone:763-691-3746
Practice Address - Fax:320-679-7045
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-01
Last Update Date:2011-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife