Basic Information
| Provider Information | |||||||||
| NPI: | 1063461713 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ACHENBACH | ||||||||
| FirstName: | TRACEY | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CRNA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JAMES | ||||||||
| OtherFirstName: | TRACEY | ||||||||
| OtherMiddleName: | L | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 288 | ||||||||
| Address2: | |||||||||
| City: | HUNTSVILLE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 358040288 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2568806711 | ||||||||
| FaxNumber: | 2568806712 | ||||||||
| Practice Location | |||||||||
| Address1: | 721 MADISON ST SE | ||||||||
| Address2: | |||||||||
| City: | HUNTSVILLE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 358014408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2568806711 | ||||||||
| FaxNumber: | 2568806712 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2006 | ||||||||
| LastUpdateDate: | 12/11/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 1-105829 | AL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 51531739 | 01 | AL | BLUE SHIELD | OTHER | 51002179 | 01 | AL | BLUE SHIELD | OTHER | 051556509 | 05 | AL | MEDICAID | 051531739 | 05 | AL | MEDICAID |