Basic Information
| Provider Information | |||||||||
| NPI: | 1417120825 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DOVI | ||||||||
| FirstName: | TRACEY | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | APNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2801 W KINNICKINNIC RIVER PKWY | ||||||||
| Address2: | SUITE 840 | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532153669 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4146493530 | ||||||||
| FaxNumber: | 4146493529 | ||||||||
| Practice Location | |||||||||
| Address1: | 2801 W KINNICKINNIC RIVER PKWY | ||||||||
| Address2: | SUITE 840 | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532153669 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4146493530 | ||||||||
| FaxNumber: | 4146493529 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/07/2008 | ||||||||
| LastUpdateDate: | 12/01/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | 3407-33 | WI | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363L00000X | 3407 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 36061700 | 05 | WI | MEDICAID |