Provider Demographics
NPI:1699726869
Name:HOULE, TRACY L (APRN)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:L
Last Name:HOULE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:L
Other - Last Name:HOLT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:12 ROLLING RIDGE CT
Mailing Address - Street 2:
Mailing Address - City:PROSPECT
Mailing Address - State:CT
Mailing Address - Zip Code:06712-1737
Mailing Address - Country:US
Mailing Address - Phone:203-758-0836
Mailing Address - Fax:203-758-0836
Practice Address - Street 1:204 KEEGAN RD
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:CT
Practice Address - Zip Code:06782-2608
Practice Address - Country:US
Practice Address - Phone:860-340-8280
Practice Address - Fax:860-283-9851
Is Sole Proprietor?:No
Enumeration Date:2006-05-13
Last Update Date:2012-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002671364SM0705X
CT2671363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No364SM0705XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistMedical-Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004247963Medicaid
CT890000514Medicare ID - Type Unspecified
CT004247963Medicaid