Provider Demographics
NPI:1013340108
Name:TICCONY, TRACEY RENEE (NPC)
Entity Type:Individual
Prefix:MS
First Name:TRACEY
Middle Name:RENEE
Last Name:TICCONY
Suffix:
Gender:F
Credentials:NPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:455 BARCLAY CIR
Mailing Address - Street 2:SUITE D
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48307-4774
Mailing Address - Country:US
Mailing Address - Phone:248-852-9596
Mailing Address - Fax:248-852-9453
Practice Address - Street 1:455 BARCLAY CIR
Practice Address - Street 2:SUITE D
Practice Address - City:ROCHESTER HILLS
Practice Address - State:MI
Practice Address - Zip Code:48307-4774
Practice Address - Country:US
Practice Address - Phone:248-852-9596
Practice Address - Fax:248-852-9453
Is Sole Proprietor?:No
Enumeration Date:2013-08-13
Last Update Date:2013-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704269996163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse