Provider Demographics
NPI:1639820848
Name:TRACY, KIMBERLY NICOLE
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:NICOLE
Last Name:TRACY
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 1:1484 N M 52
Mailing Address - Street 2:
Mailing Address - City:OWOSSO
Mailing Address - State:MI
Mailing Address - Zip Code:48867-1235
Mailing Address - Country:US
Mailing Address - Phone:770-373-5822
Mailing Address - Fax:248-712-4381
Practice Address - Street 1:1484 N M 52
Practice Address - Street 2:
Practice Address - City:OWOSSO
Practice Address - State:MI
Practice Address - Zip Code:48867-1235
Practice Address - Country:US
Practice Address - Phone:770-373-5822
Practice Address - Fax:248-712-4381
Is Sole Proprietor?:No
Enumeration Date:2022-01-10
Last Update Date:2022-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI172V00000X
156F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No156F00000XEye and Vision Services ProvidersTechnician/Technologist