Provider Demographics
NPI:1154479632
Name:OZANICH, TRACY (LMP)
Entity Type:Individual
Prefix:MISS
First Name:TRACY
Middle Name:
Last Name:OZANICH
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1630 228TH ST SE APT E202
Mailing Address - Street 2:
Mailing Address - City:BOTHELL
Mailing Address - State:WA
Mailing Address - Zip Code:98021-7436
Mailing Address - Country:US
Mailing Address - Phone:425-697-5188
Mailing Address - Fax:425-678-1928
Practice Address - Street 1:23303 HIGHWAY 99 STE G
Practice Address - Street 2:
Practice Address - City:EDMONDS
Practice Address - State:WA
Practice Address - Zip Code:98026-8762
Practice Address - Country:US
Practice Address - Phone:425-697-5188
Practice Address - Fax:425-673-1928
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00016350174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0202662OtherLABOR & INDUSTRIES PIN#