Provider Demographics
NPI:1144662032
Name:LEACH, TRACY (NNP-BC)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:LEACH
Suffix:
Gender:F
Credentials:NNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:707 HOLLYBROOK DR
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75605-2410
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:707 HOLLYBROOK DR
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75605-2410
Practice Address - Country:US
Practice Address - Phone:903-757-6042
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-22
Last Update Date:2017-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP124269363LN0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0005XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal, Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX325841004Medicaid
TX75-2616977-042OtherTRICARE
TXP01813068OtherRAIL ROAD MEDICARE
TX8401MCOtherBCBS
TX8401MCOtherBCBS