Healthcare Provider Details

I. General information

NPI: 1639779523
Provider Name (Legal Business Name): TRACIE LYN HANSEN B.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: TRACIE LYN BURRUP

II. Dates (important events)

Enumeration Date: 10/29/2020
Last Update Date: 10/09/2026
Certification Date: 10/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1246 YELLOWSTONE AVE STE B4
POCATELLO ID
83201-4372
US

IV. Provider business mailing address

1246 YELLOWSTONE AVE STE B4
POCATELLO ID
83201-4372
US

V. Phone/Fax

Practice location:
  • Phone: 208-705-1009
  • Fax:
Mailing address:
  • Phone: 208-705-1009
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberCPSS055
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: