Provider Demographics
NPI:1255629093
Name:MCKINNEY, TRACEY ZAAKIRA (BAS)
Entity type:Individual
Prefix:MS
First Name:TRACEY
Middle Name:ZAAKIRA
Last Name:MCKINNEY
Suffix:
Gender:F
Credentials:BAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1923 GREY FALCON CIR SW
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32962-8609
Mailing Address - Country:US
Mailing Address - Phone:772-532-6289
Mailing Address - Fax:772-675-1881
Practice Address - Street 1:1923 GREY FALCON CIR SW
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32962-8609
Practice Address - Country:US
Practice Address - Phone:772-532-6289
Practice Address - Fax:772-675-1881
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-14
Last Update Date:2011-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL687088196Medicaid
FL687088198Medicaid