Healthcare Provider Details

I. General information

NPI: 1508617655
Provider Name (Legal Business Name): TRACEY ZIMMER RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2024
Last Update Date: 03/28/2024
Certification Date: 03/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2050 FAIRMONT DR
SAN LEANDRO CA
94578-1001
US

IV. Provider business mailing address

2025 W AVENUE 136TH APT A
SAN LEANDRO CA
94577-4158
US

V. Phone/Fax

Practice location:
  • Phone: 510-895-5502
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number95264874
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: