Provider Demographics
NPI:1073212148
Name:EDWARDS, TRACY MARIE
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:MARIE
Last Name:EDWARDS
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 1:5826 BEAVER RUN RD SW
Mailing Address - Street 2:
Mailing Address - City:PATASKALA
Mailing Address - State:OH
Mailing Address - Zip Code:43062-9532
Mailing Address - Country:US
Mailing Address - Phone:614-439-2385
Mailing Address - Fax:
Practice Address - Street 1:5826 BEAVER RUN RD SW
Practice Address - Street 2:
Practice Address - City:PATASKALA
Practice Address - State:OH
Practice Address - Zip Code:43062-9532
Practice Address - Country:US
Practice Address - Phone:614-439-2385
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-28
Last Update Date:2023-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHRL890616OtherOHIO MOTOR VEHICLE BUREAU