Provider Demographics
NPI:1548474463
Name:RESPESS, TRACEY BLACK (FNP)
Entity type:Individual
Prefix:MRS
First Name:TRACEY
Middle Name:BLACK
Last Name:RESPESS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:MISS
Other - First Name:TRACEY
Other - Middle Name:LEIGH
Other - Last Name:BLACK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7684 BROAD CREEK RD
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27889-7796
Mailing Address - Country:US
Mailing Address - Phone:252-940-1502
Mailing Address - Fax:
Practice Address - Street 1:740 BRAGAW LANE
Practice Address - Street 2:
Practice Address - City:CHOCOWINITY
Practice Address - State:NC
Practice Address - Zip Code:27817
Practice Address - Country:US
Practice Address - Phone:252-946-9562
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-09
Last Update Date:2020-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC005002930363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC005002930OtherSTATE LICENSE NUMBER
NC005002930OtherSTATE LICENSE NUMBER