Healthcare Provider Details

I. General information

NPI: 1114609104
Provider Name (Legal Business Name): ALLISON THERESA TRACY FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2023
Last Update Date: 08/01/2023
Certification Date: 06/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1512 4TH ST NE
WATERTOWN SD
57201-6824
US

IV. Provider business mailing address

18025 468TH AVE
CLEAR LAKE SD
57226-5320
US

V. Phone/Fax

Practice location:
  • Phone: 605-884-0100
  • Fax:
Mailing address:
  • Phone: 605-520-0302
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCP002916
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: