Healthcare Provider Details

I. General information

NPI: 1669016093
Provider Name (Legal Business Name): TRACIE ROSS APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/29/2019
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

440 E BROADWAY STE 300
EUGENE OR
97401-3352
US

IV. Provider business mailing address

6451 E HAVEN WAY
ALVATON KY
42122-8511
US

V. Phone/Fax

Practice location:
  • Phone: 541-762-0500
  • Fax:
Mailing address:
  • Phone: 615-300-8938
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number10039235
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number3018436
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAP61011870
License Number StateWA
# 4
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number26517
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: