Provider Demographics
NPI:1346472057
Name:ROCKEFELLER, TRACY L (CRNP)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:L
Last Name:ROCKEFELLER
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1154 BEAVER LAKE DR
Mailing Address - Street 2:
Mailing Address - City:LAKE ARIEL
Mailing Address - State:PA
Mailing Address - Zip Code:18436-8013
Mailing Address - Country:US
Mailing Address - Phone:267-401-0669
Mailing Address - Fax:
Practice Address - Street 1:1258 PURDYTOWN TPKE
Practice Address - Street 2:
Practice Address - City:LAKEVILLE
Practice Address - State:PA
Practice Address - Zip Code:18438-6793
Practice Address - Country:US
Practice Address - Phone:570-647-9277
Practice Address - Fax:570-227-0084
Is Sole Proprietor?:No
Enumeration Date:2009-08-13
Last Update Date:2024-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP0104122084P0802X, 363LA2200X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Psychiatry
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health