Provider Demographics
NPI:1821674078
Name:MUTHAMIA, TRACY
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:MUTHAMIA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:
Other - Last Name:MUTHAMIA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CRNP-FNP
Mailing Address - Street 1:2003 DAVIDSONVILLE RD
Mailing Address - Street 2:
Mailing Address - City:CROFTON
Mailing Address - State:MD
Mailing Address - Zip Code:21114-1317
Mailing Address - Country:US
Mailing Address - Phone:410-721-3762
Mailing Address - Fax:
Practice Address - Street 1:2003 DAVIDSONVILLE RD
Practice Address - Street 2:
Practice Address - City:CROFTON
Practice Address - State:MD
Practice Address - Zip Code:21114-1317
Practice Address - Country:US
Practice Address - Phone:410-721-3762
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-18
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR194960363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily