=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144707373
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TRACI SICKICH FNP- BC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/20/2018
-----------------------------------------------------
Last Update Date | 10/31/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | UNIT 3215 BOX 86TH
-----------------------------------------------------
City | APO
-----------------------------------------------------
State | AE
-----------------------------------------------------
Zip | 09094-3215
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | -479-2273
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | UNIT 3215 BOX 86TH
-----------------------------------------------------
City | APO
-----------------------------------------------------
State | AE
-----------------------------------------------------
Zip | 09094-3215
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 135536
-----------------------------------------------------
License Number State | AK
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 135536
-----------------------------------------------------
License Number State | AK
-----------------------------------------------------