Provider Demographics
NPI:1245535897
Name:NUNNALLY, TRACY DOSS (NP)
Entity type:Individual
Prefix:MR
First Name:TRACY
Middle Name:DOSS
Last Name:NUNNALLY
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6600 W 20TH ST UNIT 26
Mailing Address - Street 2:
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80634-9685
Mailing Address - Country:US
Mailing Address - Phone:970-330-2039
Mailing Address - Fax:
Practice Address - Street 1:100 S CHERRY AVE UNIT 1
Practice Address - Street 2:
Practice Address - City:EATON
Practice Address - State:CO
Practice Address - Zip Code:80615-8256
Practice Address - Country:US
Practice Address - Phone:970-454-3838
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-12
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO185357163W00000X
COAPN.0992881363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse