Provider Demographics
NPI:1700540051
Name:TRACEY, MIKKE-ANN
Entity Type:Individual
Prefix:
First Name:MIKKE-ANN
Middle Name:
Last Name:TRACEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MIKKE-ANN
Other - Middle Name:
Other - Last Name:MCINTOSH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4711 NW 51ST TER
Mailing Address - Street 2:
Mailing Address - City:TAMARAC
Mailing Address - State:FL
Mailing Address - Zip Code:33319-6310
Mailing Address - Country:US
Mailing Address - Phone:347-542-1447
Mailing Address - Fax:
Practice Address - Street 1:4711 NW 51ST TER
Practice Address - Street 2:
Practice Address - City:TAMARAC
Practice Address - State:FL
Practice Address - Zip Code:33319-6310
Practice Address - Country:US
Practice Address - Phone:347-542-1447
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-23
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9414431163W00000X
FL11030933367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse