Provider Demographics
NPI:1073126512
Name:ANDERSON, TRACY L (LPN)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:L
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:LYNNE
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPN
Mailing Address - Street 1:14541 CASTLEWOOD ST. PO BOX 426
Mailing Address - Street 2:
Mailing Address - City:WAVERLY
Mailing Address - State:NE
Mailing Address - Zip Code:68462-0426
Mailing Address - Country:US
Mailing Address - Phone:402-786-2341
Mailing Address - Fax:402-786-2799
Practice Address - Street 1:14340 CASTLEWOOD ST
Practice Address - Street 2:
Practice Address - City:WAVERLY
Practice Address - State:NE
Practice Address - Zip Code:68462-1580
Practice Address - Country:US
Practice Address - Phone:402-786-2341
Practice Address - Fax:402-786-2799
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-25
Last Update Date:2020-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE7076164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse