Provider Demographics
NPI:1033397252
Name:STEVENS, TRACY (REGISTERED NURSE)
Entity type:Individual
Prefix:MS
First Name:TRACY
Middle Name:
Last Name:STEVENS
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:280 SEWARD STREET
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14608
Mailing Address - Country:US
Mailing Address - Phone:585-201-9008
Mailing Address - Fax:585-235-4123
Practice Address - Street 1:280 SEWARD STREET
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14608
Practice Address - Country:US
Practice Address - Phone:585-201-9008
Practice Address - Fax:585-235-4123
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-11
Last Update Date:2011-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY494408-1374T00000X
NY494408163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374T00000XNursing Service Related ProvidersReligious Nonmedical Nursing Personnel
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02141808Medicaid