Provider Demographics
NPI:1760899934
Name:SKELLY, TRACEY (OD)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:
Last Name:SKELLY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:451 AMHERST ST STE 102
Mailing Address - Street 2:
Mailing Address - City:NASHUA
Mailing Address - State:NH
Mailing Address - Zip Code:03063-1200
Mailing Address - Country:US
Mailing Address - Phone:603-882-4221
Mailing Address - Fax:
Practice Address - Street 1:451 AMHERST ST STE 102
Practice Address - Street 2:
Practice Address - City:NASHUA
Practice Address - State:NH
Practice Address - Zip Code:03063-1200
Practice Address - Country:US
Practice Address - Phone:603-882-4221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-18
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG002969152W00000X
MA5050152W00000X
NH0954152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3111481Medicaid