Provider Demographics
NPI:1043336076
Name:SEVERN, TRACY (LPN)
Entity Type:Individual
Prefix:MS
First Name:TRACY
Middle Name:
Last Name:SEVERN
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1474 MCKINLEY AVE
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:OH
Mailing Address - Zip Code:44212-3336
Mailing Address - Country:US
Mailing Address - Phone:330-273-3207
Mailing Address - Fax:
Practice Address - Street 1:1474 MCKINLEY AVE
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:OH
Practice Address - Zip Code:44212-3336
Practice Address - Country:US
Practice Address - Phone:330-273-3207
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN 100324164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2118649OtherINDEPENDANT PROVIDER