Provider Demographics
NPI:1942255070
Name:TRACY, KATHY LYNNE (MD)
Entity Type:Individual
Prefix:
First Name:KATHY
Middle Name:LYNNE
Last Name:TRACY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:314 W HALE ST
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601-8439
Mailing Address - Country:US
Mailing Address - Phone:337-794-5745
Mailing Address - Fax:
Practice Address - Street 1:176 LONGVILLE CHURCH RD
Practice Address - Street 2:
Practice Address - City:LONGVILLE
Practice Address - State:LA
Practice Address - Zip Code:70652-5036
Practice Address - Country:US
Practice Address - Phone:337-794-5745
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-24
Last Update Date:2015-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA023904208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1429082Medicaid
H27349Medicare UPIN
H27349Medicare UPIN