Provider Demographics
NPI:1891951711
Name:THREAT, TRACY ANN (FNP-BC)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:ANN
Last Name:THREAT
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5555 CONNER ST STE 2691
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48213-3812
Mailing Address - Country:US
Mailing Address - Phone:313-692-8400
Mailing Address - Fax:313-692-8427
Practice Address - Street 1:5555 CONNER ST
Practice Address - Street 2:SUITE 2691
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48213-3448
Practice Address - Country:US
Practice Address - Phone:313-579-1182
Practice Address - Fax:313-579-5128
Is Sole Proprietor?:No
Enumeration Date:2008-07-30
Last Update Date:2021-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704223743363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI11971276OtherCAQH ID