Healthcare Provider Details

I. General information

NPI: 1871215954
Provider Name (Legal Business Name): TRACEY MONIQUE BROWN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2022
Last Update Date: 09/14/2022
Certification Date: 09/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 MAIN ST
WALNUTPORT PA
18088-1601
US

IV. Provider business mailing address

103 MAIN ST
WALNUTPORT PA
18088-1601
US

V. Phone/Fax

Practice location:
  • Phone: 484-262-9992
  • Fax:
Mailing address:
  • Phone: 484-262-9992
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License NumberCL194977
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: