Basic Information
| Provider Information | |||||||||
| NPI: | 1407076789 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PACITTI | ||||||||
| FirstName: | TRACY | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | NURSE PRACTITIONER | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DISTEFANO | ||||||||
| OtherFirstName: | TRACY | ||||||||
| OtherMiddleName: | LEE | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | NURSE PRACTITIONER | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 400 STANFORD RD | ||||||||
| Address2: | |||||||||
| City: | FAIRLESS HILLS | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190304010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159499529 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 280 MIDDLETOWN BLVD | ||||||||
| Address2: | |||||||||
| City: | LANGHORNE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190471816 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2675723100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2007 | ||||||||
| LastUpdateDate: | 02/27/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 26NJ01020300 | NJ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 163WR0006X | RN349942L | PA | N | Nursing Service Providers | Registered Nurse | Registered Nurse First Assistant |
No ID Information.