Healthcare Provider Details

I. General information

NPI: 1528046646
Provider Name (Legal Business Name): TRACY HAWTHORNE PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2006
Last Update Date: 08/12/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 MANSFIELD AVE
WILLIMANTIC CT
06226-2045
US

IV. Provider business mailing address

112 MANSFIELD AVE
WILLIMANTIC CT
06226-2045
US

V. Phone/Fax

Practice location:
  • Phone: 860-456-9116
  • Fax:
Mailing address:
  • Phone: 860-456-9116
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number001685
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: