Healthcare Provider Details

I. General information

NPI: 1093962722
Provider Name (Legal Business Name): TRACY MARIE PEVETO R.N., MSN, FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/25/2008
Last Update Date: 04/11/2024
Certification Date: 04/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2014 10TH ST
ORANGE TX
77630-3431
US

IV. Provider business mailing address

PO BOX 650859 DEPT 710
DALLAS TX
75265-5302
US

V. Phone/Fax

Practice location:
  • Phone: 409-266-1888
  • Fax: 409-883-3147
Mailing address:
  • Phone: 409-747-6240
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAP116915
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP116915
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: