Provider Demographics
NPI:1104968171
Name:KROB, TRACIE L (FNP)
Entity type:Individual
Prefix:
First Name:TRACIE
Middle Name:L
Last Name:KROB
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:770 BLACK FOREST LN
Mailing Address - Street 2:
Mailing Address - City:BRANSON WEST
Mailing Address - State:MO
Mailing Address - Zip Code:65737-7771
Mailing Address - Country:US
Mailing Address - Phone:417-894-9194
Mailing Address - Fax:
Practice Address - Street 1:525 BRANSON LANDING BLVD STE 306
Practice Address - Street 2:
Practice Address - City:BRANSON
Practice Address - State:MO
Practice Address - Zip Code:65616-2140
Practice Address - Country:US
Practice Address - Phone:417-335-7559
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA004382363LF0000X
TN24908363LF0000X
MO20050063342363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO427279708Medicaid
AR161375758Medicaid
AR161375758Medicaid
MO825423230Medicare PIN
MO825423268Medicare PIN