Provider Demographics
NPI:1699454702
Name:THORNTON, TRACY
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:THORNTON
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 1:2322 GARDEN SQUARE PATH
Mailing Address - Street 2:
Mailing Address - City:SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:77386-1034
Mailing Address - Country:US
Mailing Address - Phone:832-928-6465
Mailing Address - Fax:
Practice Address - Street 1:2322 GARDEN SQUARE PATH
Practice Address - Street 2:
Practice Address - City:SPRING
Practice Address - State:TX
Practice Address - Zip Code:77386-1034
Practice Address - Country:US
Practice Address - Phone:832-928-6465
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-17
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL-47666163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant