Healthcare Provider Details

I. General information

NPI: 1215258363
Provider Name (Legal Business Name): NANCYLEE TRACEY-DOUGLAS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2010
Last Update Date: 02/08/2024
Certification Date: 02/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17336 103RD RD
JAMAICA NY
11433-1306
US

IV. Provider business mailing address

17336 103RD RD
JAMAICA NY
11433-1306
US

V. Phone/Fax

Practice location:
  • Phone: 718-737-2928
  • Fax:
Mailing address:
  • Phone: 718-739-0045
  • Fax: 718-739-0102

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number575353
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: