Provider Demographics
NPI:1700173903
Name:DONIGIAN, TRACIE LEA (ANP-BC)
Entity Type:Individual
Prefix:
First Name:TRACIE
Middle Name:LEA
Last Name:DONIGIAN
Suffix:
Gender:F
Credentials:ANP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1640 FORT ST
Mailing Address - Street 2:SUITE D ATTN DENISE
Mailing Address - City:TRENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48183-2040
Mailing Address - Country:US
Mailing Address - Phone:734-391-3057
Mailing Address - Fax:734-391-3052
Practice Address - Street 1:2333 BIDDLE AVE
Practice Address - Street 2:
Practice Address - City:WYANDOTTE
Practice Address - State:MI
Practice Address - Zip Code:48192-4668
Practice Address - Country:US
Practice Address - Phone:734-246-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-07
Last Update Date:2017-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704210486363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
1144634403OtherGROUP NPI HENRY FORD WYANDOTTE
MI0H28865OtherBLUE CROSS
1144634403OtherGROUP NPI HENRY FORD WYANDOTTE