=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437361474
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TRACI L FRALIC LMP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/03/2007
-----------------------------------------------------
Last Update Date | 11/10/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 308 PINE ST
-----------------------------------------------------
City | MOUNT VERNON
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98273-3852
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-873-8643
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1500 E COLLEGE WAY STE A PMB #273
-----------------------------------------------------
City | MOUNT VERNON
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98273-5637
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-873-8643
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | MA23658
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------