Healthcare Provider Details

I. General information

NPI: 1740705631
Provider Name (Legal Business Name): TRACEY CECELE THOMAS RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/11/2017
Last Update Date: 08/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1663 EAST 17 ST.
BROOKLYN NY
11229
US

IV. Provider business mailing address

8625 VAN WYCK EXPY APT L12
BRIARWOOD NY
11435-2922
US

V. Phone/Fax

Practice location:
  • Phone: 718-339-9700
  • Fax:
Mailing address:
  • Phone: 718-206-9794
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number505796-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: