Provider Demographics
NPI:1801137229
Name:MARINO, TRACEY A (NP)
Entity type:Individual
Prefix:
First Name:TRACEY
Middle Name:A
Last Name:MARINO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1848
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49443-1848
Mailing Address - Country:US
Mailing Address - Phone:231-672-8145
Mailing Address - Fax:231-672-6179
Practice Address - Street 1:1560 E SHERMAN BLVD
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49444-1867
Practice Address - Country:US
Practice Address - Phone:231-672-8145
Practice Address - Fax:231-672-6179
Is Sole Proprietor?:No
Enumeration Date:2013-03-11
Last Update Date:2022-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704259907363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIF0113196OtherAANP CERTIFICATION