Provider Demographics
NPI:1245353531
Name:BLACKTON-KOPP, TRACEY M (RN)
Entity type:Individual
Prefix:MRS
First Name:TRACEY
Middle Name:M
Last Name:BLACKTON-KOPP
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 1:7 CASTLETON LN
Mailing Address - Street 2:
Mailing Address - City:MOORESTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:08057-3049
Mailing Address - Country:US
Mailing Address - Phone:856-642-9798
Mailing Address - Fax:
Practice Address - Street 1:261 CONNECTICUT DR
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:NJ
Practice Address - Zip Code:08016-4177
Practice Address - Country:US
Practice Address - Phone:609-387-7322
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NO11913500163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse