Healthcare Provider Details

I. General information

NPI: 1033732995
Provider Name (Legal Business Name): TRACEE TABARES FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2020
Last Update Date: 06/21/2021
Certification Date: 06/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 S MARKET ST
FREDERICK MD
21701-5527
US

IV. Provider business mailing address

702 RUSSELL AVE
GAITHERSBURG MD
20877-2606
US

V. Phone/Fax

Practice location:
  • Phone: 301-600-1506
  • Fax:
Mailing address:
  • Phone: 240-595-7659
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number0024180389
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAC003567
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number0001271471
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: