Provider Demographics
NPI:1154697167
Name:RICHARD, TRACY RENE'
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:RENE'
Last Name:RICHARD
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:PO BOX 136
Mailing Address - Street 2:
Mailing Address - City:LINGLE
Mailing Address - State:WY
Mailing Address - Zip Code:82223-0136
Mailing Address - Country:US
Mailing Address - Phone:307-837-2551
Mailing Address - Fax:
Practice Address - Street 1:601 NIOBRARA AVE
Practice Address - Street 2:
Practice Address - City:TORRINGTON
Practice Address - State:WY
Practice Address - Zip Code:82240-1522
Practice Address - Country:US
Practice Address - Phone:307-532-3035
Practice Address - Fax:949-577-4626
Is Sole Proprietor?:No
Enumeration Date:2012-03-25
Last Update Date:2021-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE101232367500000X
CO130570367500000X
COCRA-100117367500000X
WY22402.1181367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered