Healthcare Provider Details

I. General information

NPI: 1790396877
Provider Name (Legal Business Name): JENNIFER ANNE TRACY PNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2020
Last Update Date: 08/12/2020
Certification Date: 08/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

621 10TH ST
NIAGARA FALLS NY
14301-1813
US

IV. Provider business mailing address

427 HAWTHORNE PL
YOUNGSTOWN NY
14174-1324
US

V. Phone/Fax

Practice location:
  • Phone: 716-278-4000
  • Fax:
Mailing address:
  • Phone: 716-799-2500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number383152
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: