Provider Demographics
NPI:1871122457
Name:CARROLL, TRACY ELIZABETH
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:ELIZABETH
Last Name:CARROLL
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 1:71 MARY ESTHER BLVD
Mailing Address - Street 2:
Mailing Address - City:MARY ESTHER
Mailing Address - State:FL
Mailing Address - Zip Code:32569-1967
Mailing Address - Country:US
Mailing Address - Phone:850-301-0677
Mailing Address - Fax:
Practice Address - Street 1:71 MARY ESTHER BLVD
Practice Address - Street 2:
Practice Address - City:MARY ESTHER
Practice Address - State:FL
Practice Address - Zip Code:32569-1967
Practice Address - Country:US
Practice Address - Phone:850-301-0677
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-06
Last Update Date:2023-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR124240363LF0000X
FL11013899363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily