Provider Demographics
NPI:1972572022
Name:HALL, TRACEY M (NP)
Entity type:Individual
Prefix:MS
First Name:TRACEY
Middle Name:M
Last Name:HALL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MS
Other - First Name:CONNORS
Other - Middle Name:M
Other - Last Name:TRACEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:1 EATON PL
Mailing Address - Street 2:STE 23
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01608-1232
Mailing Address - Country:US
Mailing Address - Phone:508-363-6881
Mailing Address - Fax:508-363-7591
Practice Address - Street 1:1 EATON PL
Practice Address - Street 2:ST. VINCENT HOSPTIAL BREAST CARE PROGRAM ONE
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01608-1232
Practice Address - Country:US
Practice Address - Phone:508-363-6881
Practice Address - Fax:508-363-7591
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2014-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA254657363L00000X
MI4704256710363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0398756Medicaid
MAHA NP4687Medicare ID - Type Unspecified
MAQ22391Medicare UPIN