Provider Demographics
NPI:1083973739
Name:BRYAN, TRACI SUE (LPN)
Entity Type:Individual
Prefix:MRS
First Name:TRACI
Middle Name:SUE
Last Name:BRYAN
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:TRACI
Other - Middle Name:SUE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:5641 VICTORY DR
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45233-4658
Mailing Address - Country:US
Mailing Address - Phone:513-828-7191
Mailing Address - Fax:
Practice Address - Street 1:5641 VICTORY DR
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45233-4658
Practice Address - Country:US
Practice Address - Phone:513-828-7191
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-15
Last Update Date:2012-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN076996164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse