Healthcare Provider Details

I. General information

NPI: 1194785162
Provider Name (Legal Business Name): TRACEY ELIZABETH WILEY CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TRACEY ELIZABETH OBERHOLZER

II. Dates (important events)

Enumeration Date: 03/24/2006
Last Update Date: 04/29/2020
Certification Date: 04/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 ST PAUL DR STE 210
CHAMBERSBURG PA
17201-1035
US

IV. Provider business mailing address

785 5TH AVENUE SUITE 3
CHAMBERSBURG PA
17201-4232
US

V. Phone/Fax

Practice location:
  • Phone: 717-217-6820
  • Fax: 717-217-6942
Mailing address:
  • Phone: 717-263-9555
  • Fax: 717-217-4217

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberTP005855B
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: