MEDICARE: TRACEY DENISE SMITH

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	363LF0000X	Family Nurse Practitioner	2019005978	MO

General Provider Information

NPI Number	:	1417512039
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TRACEY DENISE SMITH

Provider Business Mailing Address
First Line	:	12453 CHARLOTTE ST
Second Line	:
City	:	KANSAS CITY
State	:	MO
Zip	:	64146-1310
Country	:	US
Telephone Number	:	913-788-0227
Fax Number	:

Provider Business Practice Location Address
First Line	:	12453 CHARLOTTE ST
Second Line	:
City	:	KANSAS CITY
State	:	MO
Zip	:	64146-1310
Country	:	US
Telephone Number	:	913-788-0227
Fax Number	:

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

Provider Enumeration Date	:	05/08/2019
Last Update Date	:	05/08/2019

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Directions to “ TRACEY DENISE SMITH ” Practice Location

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