Provider Demographics
NPI:1043554900
Name:DAVIS, TRACY (LPN)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:DAVIS
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:PO BOX 2803
Mailing Address - Street 2:
Mailing Address - City:REDMOND
Mailing Address - State:WA
Mailing Address - Zip Code:98073-2803
Mailing Address - Country:US
Mailing Address - Phone:425-496-4354
Mailing Address - Fax:
Practice Address - Street 1:16601 NE 80TH ST
Practice Address - Street 2:#404
Practice Address - City:REDMOND
Practice Address - State:WA
Practice Address - Zip Code:98052-6643
Practice Address - Country:US
Practice Address - Phone:425-496-4354
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-16
Last Update Date:2014-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALP00057085164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse