Provider Demographics
NPI:1053956532
Name:HENLINE, TRACIE JO (NP)
Entity type:Individual
Prefix:
First Name:TRACIE
Middle Name:JO
Last Name:HENLINE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:176 BERNE RD
Mailing Address - Street 2:
Mailing Address - City:BAD AXE
Mailing Address - State:MI
Mailing Address - Zip Code:48413-9034
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:75 BUSCHLEN RD
Practice Address - Street 2:
Practice Address - City:BAD AXE
Practice Address - State:MI
Practice Address - Zip Code:48413
Practice Address - Country:US
Practice Address - Phone:989-623-9300
Practice Address - Fax:989-269-0243
Is Sole Proprietor?:No
Enumeration Date:2019-11-08
Last Update Date:2024-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704269229363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily