Healthcare Provider Details

I. General information

NPI: 1942472857
Provider Name (Legal Business Name): TRACY MARIANO WHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2008
Last Update Date: 09/26/2022
Certification Date: 09/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1481 W 10TH ST
INDIANAPOLIS IN
46202-2803
US

IV. Provider business mailing address

1481 W 10TH ST
INDIANAPOLIS IN
46202-2803
US

V. Phone/Fax

Practice location:
  • Phone: 317-988-4917
  • Fax: 317-988-4929
Mailing address:
  • Phone: 317-988-4917
  • Fax: 317-988-4929

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number71003170B
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number28143782A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License Number28143782A
License Number StateIN
# 4
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number71003170A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: