Healthcare Provider Details

I. General information

NPI: 1396271318
Provider Name (Legal Business Name): TRACEY MACDONALD R.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2017
Last Update Date: 11/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1443 HARTFORD AVE
JOHNSTON RI
02919-3224
US

IV. Provider business mailing address

117 ELLENFIELD ST STE 101
PROVIDENCE RI
02905-4513
US

V. Phone/Fax

Practice location:
  • Phone: 401-273-8100
  • Fax: 401-861-8696
Mailing address:
  • Phone: 401-444-6779
  • Fax: 401-444-6912

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN50941
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: