Healthcare Provider Details

I. General information

NPI: 1467032946
Provider Name (Legal Business Name): TRACY LEVETT MASON PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2021
Last Update Date: 04/09/2021
Certification Date: 03/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16823 ARROW BLVD
FONTANA CA
92335-3803
US

IV. Provider business mailing address

7750 DATE CT
FONTANA CA
92336-2585
US

V. Phone/Fax

Practice location:
  • Phone: 909-355-3888
  • Fax:
Mailing address:
  • Phone: 208-283-9317
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95015984
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: