Provider Demographics
NPI:1861410979
Name:EZELLE, TRACY A (ARNP)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:A
Last Name:EZELLE
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 280
Mailing Address - Street 2:
Mailing Address - City:GULF BREEZE
Mailing Address - State:FL
Mailing Address - Zip Code:32562-0280
Mailing Address - Country:US
Mailing Address - Phone:850-932-5055
Mailing Address - Fax:850-932-1404
Practice Address - Street 1:400 GULF BREEZE PKWY STE 300
Practice Address - Street 2:
Practice Address - City:GULF BREEZE
Practice Address - State:FL
Practice Address - Zip Code:32561-4458
Practice Address - Country:US
Practice Address - Phone:850-932-5055
Practice Address - Fax:850-932-1404
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP2049062363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL307471400Medicaid