Provider Demographics
NPI:1750667259
Name:ALLEN, TRACY LYN (APRN/FNP-C)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:LYN
Last Name:ALLEN
Suffix:
Gender:F
Credentials:APRN/FNP-C
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:LYN
Other - Last Name:SUMMERER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN/FNP-C
Mailing Address - Street 1:189 SUMMER STREET
Mailing Address - Street 2:MINUTE CLINIC (INSIDE CVS)
Mailing Address - City:KINGSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02364
Mailing Address - Country:US
Mailing Address - Phone:781-585-6581
Mailing Address - Fax:781-585-0197
Practice Address - Street 1:189 SUMMER STREET
Practice Address - Street 2:MINUTE CLINIC (INSIDE CVS)
Practice Address - City:KINGSTON
Practice Address - State:MA
Practice Address - Zip Code:02364
Practice Address - Country:US
Practice Address - Phone:781-585-6581
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-27
Last Update Date:2014-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT099887163W00000X
MA2264530163W00000X
CT4852363LF0000X
MARN2264530363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004235900Medicaid
CT004235900Medicaid