Healthcare Provider Details

I. General information

NPI: 1629632013
Provider Name (Legal Business Name): KAITLYNN TRACY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2019
Last Update Date: 04/16/2025
Certification Date: 04/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8900 VAN WYCK EXPY
RICHMOND HILL NY
11418-2832
US

IV. Provider business mailing address

600 S PAULINA ST STE 403
CHICAGO IL
60612-3806
US

V. Phone/Fax

Practice location:
  • Phone: 718-206-6000
  • Fax:
Mailing address:
  • Phone: 815-404-3544
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number335793
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: