Provider Demographics
NPI:1770883977
Name:CLARK, TRACY ANN (CRNA)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:ANN
Last Name:CLARK
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18630 BABLER MEADOWS DR
Mailing Address - Street 2:
Mailing Address - City:WILDWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63038-1174
Mailing Address - Country:US
Mailing Address - Phone:952-818-2651
Mailing Address - Fax:
Practice Address - Street 1:232 S WOODS MILL RD
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-3417
Practice Address - Country:US
Practice Address - Phone:314-205-6917
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-22
Last Update Date:2011-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010035831367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered