Provider Demographics
NPI:1255456620
Name:VARGAS, TRACI RENEE (NP)
Entity type:Individual
Prefix:MRS
First Name:TRACI
Middle Name:RENEE
Last Name:VARGAS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MISS
Other - First Name:TRACI
Other - Middle Name:RENEE
Other - Last Name:GORMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:10418 VALLEY BLVD
Mailing Address - Street 2:
Mailing Address - City:EL MONTE
Mailing Address - State:CA
Mailing Address - Zip Code:91731-3600
Mailing Address - Country:US
Mailing Address - Phone:626-453-8466
Mailing Address - Fax:626-453-8465
Practice Address - Street 1:10418 VALLEY BLVD
Practice Address - Street 2:
Practice Address - City:EL MONTE
Practice Address - State:CA
Practice Address - Zip Code:91731-3600
Practice Address - Country:US
Practice Address - Phone:626-453-8466
Practice Address - Fax:626-453-8465
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2012-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA462956163W00000X
CA16153363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CANP16153OtherBOARD OF NURSING CA
CARN462956OtherBOARD OF NURSING CA