Basic Information
| Provider Information | |||||||||
| NPI: | 1881851020 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | TRACY | ||||||||
| MiddleName: | |||||||||
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| Credential: | RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4225 GOLDEN VALLEY ROAD | ||||||||
| Address2: | |||||||||
| City: | GOLDEN VALLEY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554224215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7635880661 | ||||||||
| FaxNumber: | 7633024346 | ||||||||
| Practice Location | |||||||||
| Address1: | 4225 GOLDEN VALLEY ROAD | ||||||||
| Address2: | |||||||||
| City: | GOLDEN VALLEY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554224215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7635880661 | ||||||||
| FaxNumber: | 7633024346 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2008 | ||||||||
| LastUpdateDate: | 11/30/2011 | ||||||||
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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 | 163W00000X | R-125701-4 | MN | Y | Nursing Service Providers | Registered Nurse |
No ID Information.