Healthcare Provider Details

I. General information

NPI: 1558329433
Provider Name (Legal Business Name): AUDREY TRACEY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2006
Last Update Date: 04/02/2020
Certification Date: 04/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

87 NORTH MAIN STREET
LEOMINSTER MA
01453
US

IV. Provider business mailing address

87 NORTH MAIN STREET
LEOMINSTER MA
01453
US

V. Phone/Fax

Practice location:
  • Phone: 798-534-8701
  • Fax: 978-534-8705
Mailing address:
  • Phone: 978-534-8701
  • Fax: 978-534-8705

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number152307
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: