Provider Demographics
NPI:1548693682
Name:JOHNSTON, TRACY LYNN (NP- C)
Entity type:Individual
Prefix:MS
First Name:TRACY
Middle Name:LYNN
Last Name:JOHNSTON
Suffix:
Gender:F
Credentials:NP- C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1910 UNIVERSITY DR
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83725-1351
Mailing Address - Country:US
Mailing Address - Phone:208-426-1459
Mailing Address - Fax:208-426-3005
Practice Address - Street 1:1910 UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83725-1351
Practice Address - Country:US
Practice Address - Phone:208-426-1459
Practice Address - Fax:208-426-3005
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-13
Last Update Date:2013-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP-1311 A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily