Provider Demographics
NPI:1053980565
Name:LEVERIDGE, TRACIE DIANE
Entity type:Individual
Prefix:
First Name:TRACIE
Middle Name:DIANE
Last Name:LEVERIDGE
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 1:1 SAINT ROBBY CT
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-7637
Mailing Address - Country:US
Mailing Address - Phone:817-269-8289
Mailing Address - Fax:
Practice Address - Street 1:5616 LONE STAR PKWY
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78253-2200
Practice Address - Country:US
Practice Address - Phone:210-281-5066
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-19
Last Update Date:2021-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1030791367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife