Healthcare Provider Details

I. General information

NPI: 1164206587
Provider Name (Legal Business Name): TRACY ANN PETLESKI DNP, CNL-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2023
Last Update Date: 08/24/2023
Certification Date: 08/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

308 QUEENS RD APT 20
CHARLOTTE NC
28204-3209
US

IV. Provider business mailing address

308 QUEENS RD APT 20
CHARLOTTE NC
28204-3209
US

V. Phone/Fax

Practice location:
  • Phone: 704-351-6062
  • Fax:
Mailing address:
  • Phone: 704-351-6062
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number101248
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: