MEDICARE: TRACI J VAN GORDEN CFNP

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	363LF0000X	Family Nurse Practitioner	4704252117	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1679513451
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TRACI J VAN GORDEN CFNP

Provider Business Mailing Address
First Line	:	104 S LAKEVIEW AVE
Second Line	:
City	:	STURGIS
State	:	MI
Zip	:	49091-1947
Country	:	US
Telephone Number	:	269-319-8850
Fax Number	:

Provider Business Practice Location Address
First Line	:	104 S LAKEVIEW AVE
Second Line	:
City	:	STURGIS
State	:	MI
Zip	:	49091-1947
Country	:	US
Telephone Number	:	269-319-8850
Fax Number	:	269-464-0101

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

Provider Enumeration Date	:	06/08/2006
Last Update Date	:	11/05/2020

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