Healthcare Provider Details

I. General information

NPI: 1093718173
Provider Name (Legal Business Name): TRACY A DONAHUE FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2005
Last Update Date: 07/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14540 PRAIRIE LAKES BLVD N SUITE 207
NOBLESVILLE IN
46060-4366
US

IV. Provider business mailing address

14540 PRAIRIE LAKES BLVD N SUITE 207
NOBLESVILLE IN
46060-4366
US

V. Phone/Fax

Practice location:
  • Phone: 317-621-2455
  • Fax: 317-355-6166
Mailing address:
  • Phone: 317-621-2455
  • Fax: 317-355-6166

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71000396A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: