Provider Demographics
NPI:1093223869
Name:CANESTARO, TRACY (RN)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:CANESTARO
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:
Other - Last Name:SCHIEFEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:100 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:ELMIRA
Mailing Address - State:NY
Mailing Address - Zip Code:14901-2849
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:ELMIRA
Practice Address - State:NY
Practice Address - Zip Code:14901
Practice Address - Country:US
Practice Address - Phone:607-737-4784
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-16
Last Update Date:2018-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY372668-1163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1093223869Medicaid