Provider Demographics
NPI:1457943706
Name:PROULX, TRACY A (FNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:A
Last Name:PROULX
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4580 S NICHOLSON AVE
Mailing Address - Street 2:
Mailing Address - City:CUDAHY
Mailing Address - State:WI
Mailing Address - Zip Code:53110-1360
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4580 S NICHOLSON AVE
Practice Address - Street 2:
Practice Address - City:CUDAHY
Practice Address - State:WI
Practice Address - Zip Code:53110-1360
Practice Address - Country:US
Practice Address - Phone:414-326-4800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-08
Last Update Date:2021-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10747363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner