Provider Demographics
NPI:1255363453
Name:TODD, TRACEY A (NP)
Entity type:Individual
Prefix:MS
First Name:TRACEY
Middle Name:A
Last Name:TODD
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 BALDWIN GREEN CMN
Mailing Address - Street 2:
Mailing Address - City:WOBURN
Mailing Address - State:MA
Mailing Address - Zip Code:01801-1865
Mailing Address - Country:US
Mailing Address - Phone:781-376-1771
Mailing Address - Fax:781-376-4242
Practice Address - Street 1:3 BALDWIN GREEN CMN
Practice Address - Street 2:
Practice Address - City:WOBURN
Practice Address - State:MA
Practice Address - Zip Code:01801-1865
Practice Address - Country:US
Practice Address - Phone:781-376-1771
Practice Address - Fax:781-376-4242
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA235499363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0703800Medicaid
UX7924Medicare PIN
Q48358Medicare UPIN