Provider Demographics
NPI:1790977973
Name:FIFE, TRACY MELANCON (NPC)
Entity Type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:MELANCON
Last Name:FIFE
Suffix:
Gender:F
Credentials:NPC
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:LYNN
Other - Last Name:MELANCON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1111 MEDICAL CTR. BLVD.
Mailing Address - Street 2:N-613
Mailing Address - City:MARRERO
Mailing Address - State:LA
Mailing Address - Zip Code:70072
Mailing Address - Country:US
Mailing Address - Phone:504-349-6800
Mailing Address - Fax:504-349-6621
Practice Address - Street 1:1111 MEDICAL CTR. BLVD.
Practice Address - Street 2:N-613
Practice Address - City:MARRERO
Practice Address - State:LA
Practice Address - Zip Code:70072
Practice Address - Country:US
Practice Address - Phone:504-349-6800
Practice Address - Fax:504-349-6621
Is Sole Proprietor?:No
Enumeration Date:2007-08-13
Last Update Date:2013-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN078784-AP03216363LA2100X, 363LA2200X
LAAP03216363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1540315Medicaid
LA5X523Medicare PIN
LA1540315Medicaid