Provider Demographics
NPI:1255895496
Name:SMITH, TRACY L (AGNP)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:L
Last Name:SMITH
Suffix:
Gender:F
Credentials:AGNP
Other - Prefix:
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Mailing Address - Street 1:PO BOX 419052
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-9052
Mailing Address - Country:US
Mailing Address - Phone:314-543-5200
Mailing Address - Fax:314-543-5219
Practice Address - Street 1:3555 SUNSET OFFICE DR STE 107
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63127-1045
Practice Address - Country:US
Practice Address - Phone:314-543-5200
Practice Address - Fax:314-543-5219
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-22
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO2019000944207RG0100X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology