Provider Demographics
NPI:1316723539
Name:BOLLER, TRACY MICHELE (APRN)
Entity type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:MICHELE
Last Name:BOLLER
Suffix:
Gender:
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:132 FRONTIER BLVD STE 103
Mailing Address - Street 2:
Mailing Address - City:STANFORD
Mailing Address - State:KY
Mailing Address - Zip Code:40484-6516
Mailing Address - Country:US
Mailing Address - Phone:859-287-2949
Mailing Address - Fax:855-297-6367
Practice Address - Street 1:132 FRONTIER BLVD STE 103
Practice Address - Street 2:
Practice Address - City:STANFORD
Practice Address - State:KY
Practice Address - Zip Code:40484-6516
Practice Address - Country:US
Practice Address - Phone:859-287-2949
Practice Address - Fax:855-297-6367
Is Sole Proprietor?:No
Enumeration Date:2023-09-04
Last Update Date:2025-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY401008363L00000X, 363LP2300X
KY4010008363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY4010008OtherKENTUCKY BOARD OF NURSING