Healthcare Provider Details

I. General information

NPI: 1528358405
Provider Name (Legal Business Name): LUANN MARIE TRACEY FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2011
Last Update Date: 10/02/2026
Certification Date: 10/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1951 OAK ST
NILES MI
49120-3738
US

IV. Provider business mailing address

1951 OAK ST
NILES MI
49120-3738
US

V. Phone/Fax

Practice location:
  • Phone: 269-262-4749
  • Fax: 269-262-4739
Mailing address:
  • Phone: 269-262-4749
  • Fax: 269-262-4739

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704199458
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: