Provider Demographics
NPI:1073659868
Name:IRVIN, TRACIE CELESTE (LPN)
Entity Type:Individual
Prefix:MS
First Name:TRACIE
Middle Name:CELESTE
Last Name:IRVIN
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 1:69 ENTERPRISE ST
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14619-2050
Mailing Address - Country:US
Mailing Address - Phone:585-328-2413
Mailing Address - Fax:585-328-2413
Practice Address - Street 1:69 ENTERPRISE ST
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14619-2050
Practice Address - Country:US
Practice Address - Phone:585-328-2413
Practice Address - Fax:585-328-2413
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY208170-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02291601Medicaid