Provider Demographics
NPI:1053167163
Name:FREDDIE, TRACIE MICHELLE
Entity type:Individual
Prefix:
First Name:TRACIE
Middle Name:MICHELLE
Last Name:FREDDIE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7200 CAMBRIDGE ST STE P205
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-4202
Mailing Address - Country:US
Mailing Address - Phone:832-722-5655
Mailing Address - Fax:
Practice Address - Street 1:3410 SNOWBLOSSOM CT
Practice Address - Street 2:
Practice Address - City:PEARLAND
Practice Address - State:TX
Practice Address - Zip Code:77581-3300
Practice Address - Country:US
Practice Address - Phone:832-722-5655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-29
Last Update Date:2024-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1108189363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health