Provider Demographics
NPI:1891248720
Name:PENNER, TRACI M (APRN)
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:M
Last Name:PENNER
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1725
Mailing Address - Street 2:
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NE
Mailing Address - Zip Code:68802-1725
Mailing Address - Country:US
Mailing Address - Phone:308-398-6400
Mailing Address - Fax:308-398-6408
Practice Address - Street 1:3610 RICHMOND CIR STE 100
Practice Address - Street 2:
Practice Address - City:GRAND ISLAND
Practice Address - State:NE
Practice Address - Zip Code:68803-3910
Practice Address - Country:US
Practice Address - Phone:308-398-6400
Practice Address - Fax:308-398-6408
Is Sole Proprietor?:No
Enumeration Date:2016-07-27
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA144741363L00000X
NE112074363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner