Healthcare Provider Details

I. General information

NPI: 1740452457
Provider Name (Legal Business Name): CAROLINE TRACEY FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2008
Last Update Date: 05/28/2025
Certification Date: 05/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

US 191 & AZ 264
GANADO AZ
86505
US

IV. Provider business mailing address

US 191 & AZ 264 BOX 457
GANADO AZ
86505-0457
US

V. Phone/Fax

Practice location:
  • Phone: 928-755-4933
  • Fax: 928-755-4831
Mailing address:
  • Phone: 928-755-4632
  • Fax: 928-755-4831

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP3896
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: