Healthcare Provider Details

I. General information

NPI: 1932682473
Provider Name (Legal Business Name): TRACY A BOLTON APNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2018
Last Update Date: 09/03/2022
Certification Date: 08/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10101 W WISCONSIN AVE
MILWAUKEE WI
53226-4861
US

IV. Provider business mailing address

10101 W WISCONSIN AVE
MILWAUKEE WI
53226-4861
US

V. Phone/Fax

Practice location:
  • Phone: 414-454-8460
  • Fax:
Mailing address:
  • Phone: 414-454-8460
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number8649-33
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number183925-30
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: