Provider Demographics
NPI:1720305683
Name:SCULLIN, TRACI BADEUSZ (NP)
Entity Type:Individual
Prefix:MRS
First Name:TRACI
Middle Name:BADEUSZ
Last Name:SCULLIN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7262 FARM ROAD 1734
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:TX
Mailing Address - Zip Code:75455-1730
Mailing Address - Country:US
Mailing Address - Phone:903-818-0014
Mailing Address - Fax:
Practice Address - Street 1:2001 N JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:TX
Practice Address - Zip Code:75455-2371
Practice Address - Country:US
Practice Address - Phone:903-577-6080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-30
Last Update Date:2012-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX698610363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner