Healthcare Provider Details

I. General information

NPI: 1174319370
Provider Name (Legal Business Name): TRACY KOWALSKI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2025
Last Update Date: 04/16/2025
Certification Date: 04/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

52 HUCKLEBERRY LN
NEW EGYPT NJ
08533-2832
US

IV. Provider business mailing address

52 HUCKLEBERRY LN
NEW EGYPT NJ
08533-2832
US

V. Phone/Fax

Practice location:
  • Phone: 631-721-6369
  • Fax:
Mailing address:
  • Phone: 631-721-6369
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374700000X
TaxonomyTechnician
License Number25-419655
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: