MEDICARE: TRACY LYNN CANNELL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	367500000X	Certified Registered Nurse Anesthetist	764457	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	8004UH	OTHER	TX	BCBS TX
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1295166023
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TRACY LYNN CANNELL

Provider Business Mailing Address
First Line	:	3205 CHAPARRAL LN
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76109-2006
Country	:	US
Telephone Number	:	817-205-1063
Fax Number	:

Provider Business Practice Location Address
First Line	:	3205 CHAPARRAL LN
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76109-2006
Country	:	US
Telephone Number	:	817-205-1063
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/04/2013
Last Update Date	:	06/27/2024

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