Healthcare Provider Details

I. General information

NPI: 1376597393
Provider Name (Legal Business Name): TRACI R FISHER CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TRACI POLLY

II. Dates (important events)

Enumeration Date: 05/22/2006
Last Update Date: 05/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

245 CHESAPEAKE AVE
NEWPORT NEWS VA
23607-6038
US

IV. Provider business mailing address

856 J CLYDE MORRIS BLVD SUITE A
NEWPORT NEWS VA
23601-1318
US

V. Phone/Fax

Practice location:
  • Phone: 757-534-9770
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number0024174669
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberSP008121
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: