Provider Demographics
NPI:1124585369
Name:BAKER, TRACEY LYNN
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:LYNN
Last Name:BAKER
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 1:679 TOWNCREST DR
Mailing Address - Street 2:
Mailing Address - City:BEAVERCREEK
Mailing Address - State:OH
Mailing Address - Zip Code:45434-5889
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2660 DAYTON XENIA RD
Practice Address - Street 2:
Practice Address - City:BEAVERCREEK
Practice Address - State:OH
Practice Address - Zip Code:45434-6416
Practice Address - Country:US
Practice Address - Phone:937-458-2481
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-25
Last Update Date:2019-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.270493163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool