Provider Demographics
NPI:1750581146
Name:JOHNSON, TRACY HARRIS (APRN)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:HARRIS
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:APRN
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 950202
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40295-0202
Mailing Address - Country:US
Mailing Address - Phone:502-272-5100
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:1930 BISHOP LN
Practice Address - Street 2:STE. 1600
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40218-1921
Practice Address - Country:US
Practice Address - Phone:502-272-5044
Practice Address - Fax:502-272-5121
Is Sole Proprietor?:No
Enumeration Date:2007-07-23
Last Update Date:2011-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY5222P363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
613724OtherANTHEM/NHC
000023036JOtherHUMANA/NHC
KY7100018550Medicaid
KYP00411780OtherRR MEDICARE
KY50023747OtherPASSPORT
KY00533148Medicare PIN
KY50023747OtherPASSPORT