Provider Demographics
NPI:1285130930
Name:SHAW-REESE, TRACY ZELPHIA (F02180750)
Entity type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:ZELPHIA
Last Name:SHAW-REESE
Suffix:
Gender:F
Credentials:F02180750
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 N NEW BALLAS RD STE 270
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-6859
Mailing Address - Country:US
Mailing Address - Phone:314-991-6969
Mailing Address - Fax:
Practice Address - Street 1:450 N NEW BALLAS RD STE 270
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-6859
Practice Address - Country:US
Practice Address - Phone:314-991-6969
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-02
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019024919363L00000X
MOF02180750363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner