Provider Demographics
NPI:1063158244
Name:LEAK, TRACY EVELYN
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:EVELYN
Last Name:LEAK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1306 COLUMBIA RD NW APT 101
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20009-4926
Mailing Address - Country:US
Mailing Address - Phone:202-644-2856
Mailing Address - Fax:
Practice Address - Street 1:1306 COLUMBIA RD NW APT 101
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20009-4926
Practice Address - Country:US
Practice Address - Phone:202-644-2856
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-10
Last Update Date:2022-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC3008186Medicaid