Provider Demographics
NPI:1194785162
Name:WILEY, TRACEY ELIZABETH (CRNP)
Entity type:Individual
Prefix:
First Name:TRACEY
Middle Name:ELIZABETH
Last Name:WILEY
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:TRACEY
Other - Middle Name:ELIZABETH
Other - Last Name:OBERHOLZER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:785 5TH AVENUE
Mailing Address - Street 2:SUITE 3
Mailing Address - City:CHAMBERSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17201-4232
Mailing Address - Country:US
Mailing Address - Phone:717-263-9555
Mailing Address - Fax:717-217-4217
Practice Address - Street 1:12 ST PAUL DR STE 210
Practice Address - Street 2:
Practice Address - City:CHAMBERSBURG
Practice Address - State:PA
Practice Address - Zip Code:17201-1035
Practice Address - Country:US
Practice Address - Phone:717-217-6820
Practice Address - Fax:717-217-6942
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2020-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATP005855B363L00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102556669Medicaid
PATP005855BOtherLICENSE
PA867633OtherMEDICARE GROUP #
PA1007307260034OtherMEDICAID GROUP #
PA25-1716306OtherMULTIPLAN/PHCS
PA102556669 0001Medicaid
PA25-1716306OtherINTERGROUP
PA25-1716306OtherINTERGROUP
PA102556669Medicaid