MEDICARE: MRS. TRACY MICHELE BOLLER APRN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	401008	KY
2	363LP2300X	Primary Care Nurse Practitioner	401008	KY
3	363LF0000X	Family Nurse Practitioner	4010008	KY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	4010008	OTHER	KY	KENTUCKY BOARD OF NURSING

General Provider Information

NPI Number	:	1316723539
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. TRACY MICHELE BOLLER APRN

Provider Business Mailing Address
First Line	:	132 FRONTIER BLVD STE 103
Second Line	:
City	:	STANFORD
State	:	KY
Zip	:	40484-6516
Country	:	US
Telephone Number	:	859-287-2949
Fax Number	:	855-297-6367

Provider Business Practice Location Address
First Line	:	132 FRONTIER BLVD STE 103
Second Line	:
City	:	STANFORD
State	:	KY
Zip	:	40484-6516
Country	:	US
Telephone Number	:	859-287-2949
Fax Number	:	855-297-6367

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/04/2023
Last Update Date	:	04/14/2025

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