Healthcare Provider Details

I. General information

NPI: 1578290540
Provider Name (Legal Business Name): CAROLYN TRACEY FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2022
Last Update Date: 10/25/2022
Certification Date: 10/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

87 N MAIN ST
LEOMINSTER MA
01453-5507
US

IV. Provider business mailing address

554 BROOK RD
MILTON MA
02186-2824
US

V. Phone/Fax

Practice location:
  • Phone: 978-534-8701
  • Fax:
Mailing address:
  • Phone: 978-602-5328
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN2348466
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN2348466
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: