Basic Information
Provider Information | |||||||||
NPI: | 1336152172 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WARREN | ||||||||
FirstName: | TRACEY ANN | ||||||||
MiddleName: | MILLER | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | MILLER | ||||||||
OtherFirstName: | TRACEY ANN | ||||||||
OtherMiddleName: | PATRICE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PA | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 4450 S TIFFANY DR | ||||||||
Address2: |   | ||||||||
City: | WEST PALM BEACH | ||||||||
State: | FL | ||||||||
PostalCode: | 334073241 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5618449443 | ||||||||
FaxNumber: | 5618441013 | ||||||||
Practice Location | |||||||||
Address1: | 1505 DELAWARE AVE | ||||||||
Address2: |   | ||||||||
City: | FORT PIERCE | ||||||||
State: | FL | ||||||||
PostalCode: | 349503975 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7724611402 | ||||||||
FaxNumber: | 5618472306 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/14/2006 | ||||||||
LastUpdateDate: | 03/28/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA9103831 | FL | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
ID | Type | State | Issuer | Description | 292578800 | 05 | FL |   | MEDICAID |