Provider Demographics
NPI:1649617762
Name:SMART, TRACY DARLENE
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:DARLENE
Last Name:SMART
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 1:1125 W RIVER RD
Mailing Address - Street 2:
Mailing Address - City:DETROIT LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:56501-2722
Mailing Address - Country:US
Mailing Address - Phone:218-847-1388
Mailing Address - Fax:
Practice Address - Street 1:615 OAK ST
Practice Address - Street 2:
Practice Address - City:BRAINERD
Practice Address - State:MN
Practice Address - Zip Code:56401-3610
Practice Address - Country:US
Practice Address - Phone:218-454-2163
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-30
Last Update Date:2013-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR 201849-8163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health