Healthcare Provider Details

I. General information

NPI: 1114180015
Provider Name (Legal Business Name): TRACEY JO RHEAUME PNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2008
Last Update Date: 07/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 IRVING AVENUE SUITE 112 CENTER FOR NEURODEVELOPMEMTL PEDIATRICS CROUSE POB
SYRACUSE NY
13210-1624
US

IV. Provider business mailing address

750 E ADAMS ST DEPT OF PEDIATRICS
SYRACUSE NY
13210-2342
US

V. Phone/Fax

Practice location:
  • Phone: 315-464-2089
  • Fax: 315-464-6398
Mailing address:
  • Phone: 315-464-2089
  • Fax: 315-464-6398

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberF381083-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: