Basic Information
| Provider Information | |||||||||
| NPI: | 1255441143 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TRACEY | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 81 W GUADALUPE RD STE 111 | ||||||||
| Address2: | |||||||||
| City: | GILBERT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852333321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4803664490 | ||||||||
| FaxNumber: | 4808543618 | ||||||||
| Practice Location | |||||||||
| Address1: | 2800 LINCOLN ST | ||||||||
| Address2: | |||||||||
| City: | OROVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95966 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4803664490 | ||||||||
| FaxNumber: | 4808543618 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | 3595 | AZ | N | Allopathic & Osteopathic Physicians | General Practice | 208D00000X | 20A11995 | CA | Y | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 776940 | 05 | AZ | MEDICAID |