Healthcare Provider Details

I. General information

NPI: 1154697167
Provider Name (Legal Business Name): TRACY RENE' RICHARD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2012
Last Update Date: 03/12/2021
Certification Date: 03/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 NIOBRARA AVE
TORRINGTON WY
82240-1522
US

IV. Provider business mailing address

PO BOX 136
LINGLE WY
82223-0136
US

V. Phone/Fax

Practice location:
  • Phone: 307-532-3035
  • Fax: 949-577-4626
Mailing address:
  • Phone: 307-837-2551
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number101232
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number130570
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberCRA-100117
License Number StateCO
# 4
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number22402.1181
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: