Provider Demographics
NPI:1982951612
Name:RICHARDSON, TRACY CAROLYN (ACNP)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:CAROLYN
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:ACNP
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:CAROLYN
Other - Last Name:SIMON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARNP
Mailing Address - Street 1:9200 W WISCONSIN AVE
Mailing Address - Street 2:TRAUMA AND CRITICAL CARE SURGERY
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3522
Mailing Address - Country:US
Mailing Address - Phone:414-805-8623
Mailing Address - Fax:414-805-8641
Practice Address - Street 1:9200 W WISCONSIN AVE
Practice Address - Street 2:TRAUMA AND CRITICAL CARE SURGERY
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3522
Practice Address - Country:US
Practice Address - Phone:414-805-8623
Practice Address - Fax:414-805-8641
Is Sole Proprietor?:No
Enumeration Date:2012-08-13
Last Update Date:2017-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60307006363LA2100X
WI7123363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care