Provider Demographics
NPI:1245483221
Name:TRACEY, PAULINE AGATHA (FNP)
Entity type:Individual
Prefix:MS
First Name:PAULINE
Middle Name:AGATHA
Last Name:TRACEY
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6879 14TH AVE
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95820-3431
Mailing Address - Country:US
Mailing Address - Phone:916-277-6300
Mailing Address - Fax:916-277-6740
Practice Address - Street 1:6879 14TH AVE
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95820-3431
Practice Address - Country:US
Practice Address - Phone:916-277-6300
Practice Address - Fax:916-277-6740
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-04
Last Update Date:2008-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12248363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily