Healthcare Provider Details

I. General information

NPI: 1740565217
Provider Name (Legal Business Name): MS. TRACY ANN JUNKER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/17/2011
Last Update Date: 10/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2717 E DENTON AVE
SAINT FRANCIS WI
53235-5447
US

IV. Provider business mailing address

2717 E DENTON AVE
SAINT FRANCIS WI
53235-5447
US

V. Phone/Fax

Practice location:
  • Phone: 414-483-5571
  • Fax:
Mailing address:
  • Phone: 414-483-5571
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number10570-040
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: