Healthcare Provider Details

I. General information

NPI: 1760005367
Provider Name (Legal Business Name): ELLEN MARIE TRACY DNP, FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2020
Last Update Date: 09/19/2025
Certification Date: 09/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1110 HIGHLANDS PLAZA DRIVE EAST SUITE220
SAINT LOUIS MO
63110-3927
US

IV. Provider business mailing address

660 MASON RIDGE CENTER DRIVE STE 300
SAINT LOUIS MO
63141
US

V. Phone/Fax

Practice location:
  • Phone: 314-448-3791
  • Fax:
Mailing address:
  • Phone: 314-448-3791
  • Fax: 314-996-7658

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number2024013672
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNP500006857
License Number StateDC
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN500006857
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: