Active NPI
Tracy Wallace
- Administrator Registered Nurse
- Detroit, MI
National Provider Identifier
1326481755
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Administrator Registered Nurse
- License
- 4704197701
- Practice address
- 15400 W McNichols Rd
Detroit, MI 48235-3724 - Phone
- (313) 732-8272
- NPI assigned
- Apr 16, 2013
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Administrator Registered Nurse | 163WA2000X | 4704197701 | MI | Primary |
Addresses
Primary practice location
15400 W McNichols Rd
Detroit, MI 48235-3724
Mailing address
4779 Glendale
Detroit, MI 48238
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 4704197701 | MI | MD | Administrator Registered Nurse |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1366070400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1366070400000",
"number": "1326481755",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "4779 GLENDALE",
"city": "DETROIT",
"state": "MI",
"postal_code": "48238"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "15400 W MCNICHOLS RD",
"city": "DETROIT",
"state": "MI",
"postal_code": "482353724",
"telephone_number": "313-732-8272"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WALLACE",
"first_name": "TRACY",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2013-04-16",
"last_updated": "2013-04-16",
"status": "A"
},
"taxonomies": [
{
"code": "163WA2000X",
"taxonomy_group": "",
"desc": "Registered Nurse, Administrator",
"state": "MI",
"license": "4704197701",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Detroit, MI
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 16, 2013; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.