Healthcare Provider Details

I. General information

NPI: 1033450515
Provider Name (Legal Business Name): TRACEY L HEADRICK NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TRACEY L PICCININI RN

II. Dates (important events)

Enumeration Date: 03/08/2013
Last Update Date: 02/22/2021
Certification Date: 02/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 RUSH DR
SALIDA CO
81201-9627
US

IV. Provider business mailing address

1000 RUSH DR
SALIDA CO
81201-9627
US

V. Phone/Fax

Practice location:
  • Phone: 719-530-2200
  • Fax: 719-530-2001
Mailing address:
  • Phone: 719-530-2200
  • Fax: 719-530-2001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPN.0990724-NP
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: