Provider Demographics
NPI:1902172141
Name:COLLINS, TRACY ANN (ATC, LAT)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:ANN
Last Name:COLLINS
Suffix:
Gender:F
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 19TH AVE
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-3893
Mailing Address - Country:US
Mailing Address - Phone:208-791-8582
Mailing Address - Fax:208-792-2183
Practice Address - Street 1:621 19TH AVE
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-3893
Practice Address - Country:US
Practice Address - Phone:208-791-8582
Practice Address - Fax:208-792-2183
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-30
Last Update Date:2012-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDAT-1432255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer