Provider Demographics
NPI:1336152172
Name:WARREN, TRACEY ANN MILLER (PA)
Entity Type:Individual
Prefix:
First Name:TRACEY ANN
Middle Name:MILLER
Last Name:WARREN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:TRACEY ANN
Other - Middle Name:PATRICE
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:4450 S TIFFANY DR
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33407-3241
Mailing Address - Country:US
Mailing Address - Phone:561-844-9443
Mailing Address - Fax:561-844-1013
Practice Address - Street 1:1505 DELAWARE AVE
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34950-3975
Practice Address - Country:US
Practice Address - Phone:772-461-1402
Practice Address - Fax:561-847-2306
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2016-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9103831363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL292578800Medicaid
FLAZ723ZMedicare PIN