MEDICARE: TRACIE WILLSON APRN

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	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	APN.0997678-NP	CO
2	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	2023039618	MO
3	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	53-81354-121	KS

General Provider Information

NPI Number	:	1417689670
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TRACIE WILLSON APRN

Provider Business Mailing Address
First Line	:	518 BRIAN AVE UNIT 2617
Second Line	:
City	:	SILVERTHORNE
State	:	CO
Zip	:	80498-5111
Country	:	US
Telephone Number	:	913-526-5709
Fax Number	:

Provider Business Practice Location Address
First Line	:	10000 COLLEGE BLVD STE 250
Second Line	:
City	:	OVERLAND PARK
State	:	KS
Zip	:	66210-1435
Country	:	US
Telephone Number	:	913-653-3614
Fax Number	:	913-232-7742

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

Provider Enumeration Date	:	06/27/2022
Last Update Date	:	01/09/2024

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