Provider Demographics
NPI:1811400666
Name:ECKLUND, TRACEY DIANNE
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:DIANNE
Last Name:ECKLUND
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12655 RAYMOND RD
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79119-7525
Mailing Address - Country:US
Mailing Address - Phone:814-512-4755
Mailing Address - Fax:
Practice Address - Street 1:2620 RUSSEL LONG BLVD
Practice Address - Street 2:
Practice Address - City:CANYON
Practice Address - State:TX
Practice Address - Zip Code:79016-0001
Practice Address - Country:US
Practice Address - Phone:806-651-3640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-14
Last Update Date:2017-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program