Provider Demographics
NPI:1912493727
Name:ROBY, TRACEY RENEE (RN)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:RENEE
Last Name:ROBY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3271 PHEASANT RIDGE AVE SE
Mailing Address - Street 2:
Mailing Address - City:KENTWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49508-2700
Mailing Address - Country:US
Mailing Address - Phone:616-272-9896
Mailing Address - Fax:
Practice Address - Street 1:385 LEONARD ST NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-1129
Practice Address - Country:US
Practice Address - Phone:616-454-4777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-04
Last Update Date:2018-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704233792163WP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult