Provider Demographics
NPI:1992305585
Name:TETRAULT TANNER, TRACY MARIE (APRN)
Entity type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:MARIE
Last Name:TETRAULT TANNER
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:314 CHAUNCEY AVE
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03104-1506
Mailing Address - Country:US
Mailing Address - Phone:603-315-0159
Mailing Address - Fax:
Practice Address - Street 1:188 NH 101
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:NH
Practice Address - Zip Code:03110-5451
Practice Address - Country:US
Practice Address - Phone:603-663-8052
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-01
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH04006521163WC0200X
NH040065-23363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine