Healthcare Provider Details

I. General information

NPI: 1053630103
Provider Name (Legal Business Name): MAURIE DOLORES TRACY ANP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2010
Last Update Date: 04/29/2026
Certification Date: 04/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10426 BAUR BLVD
SAINT LOUIS MO
63132-1905
US

IV. Provider business mailing address

10426 BAUR BLVD
SAINT LOUIS MO
63132-1905
US

V. Phone/Fax

Practice location:
  • Phone: 314-925-0903
  • Fax: 314-764-2279
Mailing address:
  • Phone: 314-925-0903
  • Fax: 314-764-2279

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number2010012804
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: