Provider Demographics
NPI:1912541418
Name:TRACY, MIA MONIQUE (RN)
Entity Type:Individual
Prefix:
First Name:MIA
Middle Name:MONIQUE
Last Name:TRACY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1365 ASPEN DR
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21804-2062
Mailing Address - Country:US
Mailing Address - Phone:410-845-1708
Mailing Address - Fax:
Practice Address - Street 1:6040 PUBLIC LANDING RD
Practice Address - Street 2:
Practice Address - City:SNOW HILL
Practice Address - State:MD
Practice Address - Zip Code:21863-2453
Practice Address - Country:US
Practice Address - Phone:410-632-1100
Practice Address - Fax:410-632-2476
Is Sole Proprietor?:No
Enumeration Date:2019-10-29
Last Update Date:2019-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR165214163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse