Healthcare Provider Details

I. General information

NPI: 1255632196
Provider Name (Legal Business Name): TRACY JEAN TIBBETTS RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2010
Last Update Date: 11/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

167 N MAIN
TUBA CITY AZ
86045
US

IV. Provider business mailing address

167 N MAIN
TUBA CITY AZ
86045
US

V. Phone/Fax

Practice location:
  • Phone: 928-283-2501
  • Fax:
Mailing address:
  • Phone: 928-283-2501
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number33906
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: