Provider Demographics
NPI:1326862483
Name:GREEN, TRACY TAYLOR
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:TAYLOR
Last Name:GREEN
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 1:1110 ENCLAVE WAY
Mailing Address - Street 2:
Mailing Address - City:HUTTO
Mailing Address - State:TX
Mailing Address - Zip Code:78634-5334
Mailing Address - Country:US
Mailing Address - Phone:512-587-7204
Mailing Address - Fax:
Practice Address - Street 1:1110 ENCLAVE WAY
Practice Address - Street 2:
Practice Address - City:HUTTO
Practice Address - State:TX
Practice Address - Zip Code:78634-5334
Practice Address - Country:US
Practice Address - Phone:512-587-7204
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-14
Last Update Date:2024-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care