Basic Information
| Provider Information | |||||||||
| NPI: | 1467646752 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DENO-BUECHLEIN | ||||||||
| FirstName: | TRACY | ||||||||
| MiddleName: | JO | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3407 | ||||||||
| Address2: | |||||||||
| City: | EVANSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 477333407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8124503405 | ||||||||
| FaxNumber: | 8124503099 | ||||||||
| Practice Location | |||||||||
| Address1: | 600 MARY ST | ||||||||
| Address2: | |||||||||
| City: | EVANSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 477101674 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8124503405 | ||||||||
| FaxNumber: | 8124503099 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2007 | ||||||||
| LastUpdateDate: | 11/10/2014 | ||||||||
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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 | 363LF0000X | 71002456A | IN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | 71002456A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 000000539696 | 01 | IN | ANTHEM PIN - MARY ST | OTHER | 200871560 | 05 | IN | MEDICAID | 000000539855 | 01 | IN | ANTHEM - GATEWAY BLVD | OTHER |