Healthcare Provider Details

I. General information

NPI: 1023007929
Provider Name (Legal Business Name): MARJORIA MARIE TRACY CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2005
Last Update Date: 01/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

143 NORTH ST SUITE #4
AUBURN NY
13021-1852
US

IV. Provider business mailing address

143 NORTH ST SUITE #4
AUBURN NY
13021-1852
US

V. Phone/Fax

Practice location:
  • Phone: 315-252-5028
  • Fax: 315-252-5028
Mailing address:
  • Phone: 315-252-5028
  • Fax: 315-252-1587

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number0280F000858
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: