Healthcare Provider Details

I. General information

NPI: 1750687208
Provider Name (Legal Business Name): TRACIE KATHRYN MYERS TM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/01/2011
Last Update Date: 04/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22976 QUAMBA ST
BROOK PARK MN
55007-4674
US

IV. Provider business mailing address

22976 QUAMBA ST
BROOK PARK MN
55007-4674
US

V. Phone/Fax

Practice location:
  • Phone: 763-691-3746
  • Fax: 320-679-7045
Mailing address:
  • Phone: 763-691-3746
  • Fax: 320-679-7045

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: