Healthcare Provider Details

I. General information

NPI: 1336788850
Provider Name (Legal Business Name): TRACY KAY O'SHEA APRN-CNP #58842
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MS. TRACY KAY JOHNSON

II. Dates (important events)

Enumeration Date: 12/31/2019
Last Update Date: 06/14/2023
Certification Date: 06/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2211 LOMAS BLVD NE
ALBUQUERQUE NM
87106-2719
US

IV. Provider business mailing address

4520 MARTINSBURG RD NW
ALBUQUERQUE NM
87120-3857
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-2111
  • Fax:
Mailing address:
  • Phone: 505-385-4981
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number58842
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR64921
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: