Provider Demographics
NPI:1457492746
Name:TRACY, BRENDA SUE (RN)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:SUE
Last Name:TRACY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:783 N RAVENCLIFF DR
Mailing Address - Street 2:
Mailing Address - City:PUEBLO WEST
Mailing Address - State:CO
Mailing Address - Zip Code:81007-1378
Mailing Address - Country:US
Mailing Address - Phone:719-289-8938
Mailing Address - Fax:
Practice Address - Street 1:101 W 9TH ST
Practice Address - Street 2:PCCHD
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003-4103
Practice Address - Country:US
Practice Address - Phone:719-583-4362
Practice Address - Fax:719-583-4375
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2013-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO171276163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse