1366002743 NPI number — MS. KIMBERLY LYNN TRACY PNP

Table of content: MS. KIMBERLY LYNN TRACY PNP (NPI 1366002743)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366002743 NPI number — MS. KIMBERLY LYNN TRACY PNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TRACY
Provider First Name:
KIMBERLY
Provider Middle Name:
LYNN
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
PNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1366002743
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/17/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 7412039
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60674-2039
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-261-5250
Provider Business Mailing Address Fax Number:
314-261-4567

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3737 N KINGSHIGHWAY BLVD
Provider Second Line Business Practice Location Address:
STE 209
Provider Business Practice Location Address City Name:
SAINT LOUIS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63115-1736
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-261-5250
Provider Business Practice Location Address Fax Number:
314-261-4567
Provider Enumeration Date:
06/18/2019

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LP0200X , with the licence number:  2019018502 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 420078075 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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