Healthcare Provider Details

I. General information

NPI: 1770291148
Provider Name (Legal Business Name): TRACY SUE ROSE AGACNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/14/2022
Last Update Date: 10/09/2026
Certification Date: 10/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3524 N MERIDIAN ST
INDIANAPOLIS IN
46208-4486
US

IV. Provider business mailing address

3524 N MERIDIAN ST
INDIANAPOLIS IN
46208-4486
US

V. Phone/Fax

Practice location:
  • Phone: 317-925-0653
  • Fax: 317-865-7767
Mailing address:
  • Phone: 317-925-0653
  • Fax: 317-865-7767

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number71013031A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number71013031A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: