Healthcare Provider Details

I. General information

NPI: 1457943706
Provider Name (Legal Business Name): TRACY A PROULX FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2021
Last Update Date: 02/23/2021
Certification Date: 02/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4580 S NICHOLSON AVE
CUDAHY WI
53110-1360
US

IV. Provider business mailing address

4580 S NICHOLSON AVE
CUDAHY WI
53110-1360
US

V. Phone/Fax

Practice location:
  • Phone: 414-326-4800
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number10747
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: