Provider Demographics
NPI:1538726179
Name:DIXON, TRACEY MARIE
Entity type:Individual
Prefix:
First Name:TRACEY
Middle Name:MARIE
Last Name:DIXON
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 1:225 STRYJAK RD
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN TOP
Mailing Address - State:PA
Mailing Address - Zip Code:18707-9381
Mailing Address - Country:US
Mailing Address - Phone:570-709-1953
Mailing Address - Fax:
Practice Address - Street 1:2595 INTERSTATE DR STE 103
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17110-9378
Practice Address - Country:US
Practice Address - Phone:800-370-3651
Practice Address - Fax:877-515-7147
Is Sole Proprietor?:No
Enumeration Date:2019-05-20
Last Update Date:2019-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP020197363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology