Healthcare Provider Details

I. General information

NPI: 1366002743
Provider Name (Legal Business Name): KIMBERLY LYNN TRACY CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2019
Last Update Date: 06/18/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1177 E CHERRY STREET
TROY MO
63379
US

IV. Provider business mailing address

1177 E CHERRY STREET
TROY MO
63379
US

V. Phone/Fax

Practice location:
  • Phone: 636-528-3377
  • Fax: 636-528-3335
Mailing address:
  • Phone: 636-528-3377
  • Fax: 636-528-3335

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number2019018502
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: