1588427314 NPI number — TRACI L CROCKETT-TULLY CPC, CCS

Table of content: TRACI L CROCKETT-TULLY CPC, CCS (NPI 1588427314)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588427314 NPI number — TRACI L CROCKETT-TULLY CPC, CCS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CROCKETT-TULLY
Provider First Name:
TRACI
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CPC, CCS
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:
1588427314
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/05/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1037 JERAMY WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRANTS PASS
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97527-5112
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-659-2224
Provider Business Mailing Address Fax Number:
541-787-6117

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1037 JERAMY WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRANTS PASS
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97527-5112
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-659-2224
Provider Business Practice Location Address Fax Number:
541-787-6117
Provider Enumeration Date:
02/05/2024

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: 247000000X , with the licence number:  2223353-90 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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