Provider Demographics
NPI:1114514635
Name:POELLNITZ, TRACI
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:
Last Name:POELLNITZ
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 1:3054 MENTOR ST
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45206-1512
Mailing Address - Country:US
Mailing Address - Phone:513-692-7400
Mailing Address - Fax:
Practice Address - Street 1:3054 MENTOR ST
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45206-1512
Practice Address - Country:US
Practice Address - Phone:513-692-7400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-30
Last Update Date:2020-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes376J00000XNursing Service Related ProvidersHomemakerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
444OtherINDEPENDENT PROVIDER