Provider Demographics
NPI:1962980862
Name:ANSELMO, TRACY (APN)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:ANSELMO
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4401 VENTNOR AVE STE 3
Mailing Address - Street 2:
Mailing Address - City:ATLANTIC CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:08401-5736
Mailing Address - Country:US
Mailing Address - Phone:609-345-2050
Mailing Address - Fax:
Practice Address - Street 1:4401 VENTNOR AVE STE 3
Practice Address - Street 2:
Practice Address - City:ATLANTIC CITY
Practice Address - State:NJ
Practice Address - Zip Code:08401-5736
Practice Address - Country:US
Practice Address - Phone:603-345-2050
Practice Address - Fax:609-345-2052
Is Sole Proprietor?:No
Enumeration Date:2018-08-02
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00842200363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily