Provider Demographics
NPI:1154842847
Name:ROSS, TRACEY LYNNE
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:LYNNE
Last Name:ROSS
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 1:1000 LOWELLA AVE
Mailing Address - Street 2:
Mailing Address - City:PEARL CITY
Mailing Address - State:HI
Mailing Address - Zip Code:96782-3460
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:371 BRANNON ROAD
Practice Address - Street 2:BUILDING 663
Practice Address - City:SCHOFIELD BARRACKS
Practice Address - State:HI
Practice Address - Zip Code:96857
Practice Address - Country:US
Practice Address - Phone:512-749-9807
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-03
Last Update Date:2017-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI261225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant