Provider Demographics
NPI:1033258421
Name:CORNER, TRACY
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:CORNER
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 1:521 ROCKY WAY
Mailing Address - Street 2:POBOX 620703
Mailing Address - City:WOODSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:94062-4021
Mailing Address - Country:US
Mailing Address - Phone:650-599-9419
Mailing Address - Fax:
Practice Address - Street 1:136 N SAN MATEO DR
Practice Address - Street 2:SUITE 101
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94401-2777
Practice Address - Country:US
Practice Address - Phone:650-373-0777
Practice Address - Fax:650-373-0778
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT29823167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT29823OtherLPT