Healthcare Provider Details

I. General information

NPI: 1104968171
Provider Name (Legal Business Name): TRACIE L. KROB FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2007
Last Update Date: 09/20/2023
Certification Date: 09/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 BRANSON LANDING BLVD STE 306
BRANSON MO
65616-2140
US

IV. Provider business mailing address

770 BLACK FOREST LN
BRANSON WEST MO
65737-7771
US

V. Phone/Fax

Practice location:
  • Phone: 417-335-7559
  • Fax:
Mailing address:
  • Phone: 417-894-9194
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberA004382
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number24908
License Number StateTN
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number20050063342
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: