Healthcare Provider Details

I. General information

NPI: 1912201740
Provider Name (Legal Business Name): TRACY MICHELLE BRUNETTE NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TRACY MICHELLE EDWARDS

II. Dates (important events)

Enumeration Date: 01/09/2011
Last Update Date: 06/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 SE BAKER ST
MCMINNVILLE OR
97128-6038
US

IV. Provider business mailing address

320 SE BAKER ST
MCMINNVILLE OR
97128-6038
US

V. Phone/Fax

Practice location:
  • Phone: 503-474-3600
  • Fax: 503-474-3601
Mailing address:
  • Phone: 503-474-3600
  • Fax: 503-474-3601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number201050167
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: