Provider Demographics
NPI:1265063622
Name:WILLIAMS, TRACEY
Entity type:Individual
Prefix:
First Name:TRACEY
Middle Name:
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:541 FOREST AVE
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46143-1744
Mailing Address - Country:US
Mailing Address - Phone:317-937-5732
Mailing Address - Fax:
Practice Address - Street 1:55 S STATE AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46201-3802
Practice Address - Country:US
Practice Address - Phone:317-937-5732
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-03
Last Update Date:2020-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN0460368345Medicaid