Provider Demographics
NPI:1093376949
Name:MEACHAM, TRACI LYNN (LPN)
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:LYNN
Last Name:MEACHAM
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 1:28 GEORGETOWN DR APT A
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14617-5328
Mailing Address - Country:US
Mailing Address - Phone:585-785-3014
Mailing Address - Fax:
Practice Address - Street 1:28 GEORGETOWN DR APT A
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14617-5328
Practice Address - Country:US
Practice Address - Phone:585-785-3014
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-21
Last Update Date:2019-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY333632164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse