Provider Demographics
NPI:1760747943
Name:PENA, TRACY DENISE (FNP)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:DENISE
Last Name:PENA
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:DENISE
Other - Last Name:PENA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:2510 E MAIN ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:ALICE
Mailing Address - State:TX
Mailing Address - Zip Code:78332-4187
Mailing Address - Country:US
Mailing Address - Phone:361-664-4445
Mailing Address - Fax:361-664-4449
Practice Address - Street 1:2510 E MAIN ST
Practice Address - Street 2:SUITE 102
Practice Address - City:ALICE
Practice Address - State:TX
Practice Address - Zip Code:78332-4187
Practice Address - Country:US
Practice Address - Phone:361-664-4445
Practice Address - Fax:361-664-4449
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-12
Last Update Date:2013-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX694411363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner