Basic Information
| Provider Information | |||||||||
| NPI: | 1508340498 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TRACY | ||||||||
| FirstName: | LISA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 720 62ND STREET OCEAN | ||||||||
| Address2: | |||||||||
| City: | MARATHON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330502739 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3000 41ST STREET OCEAN | ||||||||
| Address2: | |||||||||
| City: | MARATHON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330502373 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3054347660 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/18/2018 | ||||||||
| LastUpdateDate: | 09/18/2018 | ||||||||
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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 | 163WP0808X | 2730022 | FL | Y | Nursing Service Providers | Registered Nurse | Psych/Mental Health |
No ID Information.