Healthcare Provider Details

I. General information

NPI: 1619094018
Provider Name (Legal Business Name): MARY TRACY BERRAN NNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/23/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 E 68TH ST 6 WEST NICU
NEW YORK NY
10021-4870
US

IV. Provider business mailing address

12 GAIL DR
NEW CITY NY
10956-3606
US

V. Phone/Fax

Practice location:
  • Phone: 212-746-0318
  • Fax: 212-746-0358
Mailing address:
  • Phone: 845-639-1981
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LN0005X
TaxonomyCritical Care Neonatal Nurse Practitioner
License NumberF350060
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: