Provider Demographics
NPI:1588427314
Name:CROCKETT-TULLY, TRACI L (CPC, CCS)
Entity type:Individual
Prefix:
First Name:TRACI
Middle Name:L
Last Name:CROCKETT-TULLY
Suffix:
Gender:F
Credentials:CPC, CCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1037 JERAMY WAY
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97527-5112
Mailing Address - Country:US
Mailing Address - Phone:541-659-2224
Mailing Address - Fax:541-787-6117
Practice Address - Street 1:1037 JERAMY WAY
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97527-5112
Practice Address - Country:US
Practice Address - Phone:541-659-2224
Practice Address - Fax:541-787-6117
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-05
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2223353-90247000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes247000000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Health InformationGroup - Single Specialty