Provider Demographics
NPI:1447709993
Name:MCDONELL, TRACY LYNN
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:LYNN
Last Name:MCDONELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:153 N U ST STE 108
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93701-2438
Mailing Address - Country:US
Mailing Address - Phone:550-445-9094
Mailing Address - Fax:
Practice Address - Street 1:153 N U ST
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93701-2438
Practice Address - Country:US
Practice Address - Phone:559-445-9094
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-26
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA100039ANMedicaid