Provider Demographics
NPI:1164661096
Name:JOHNSON, TRACI LYNN (LVN)
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:LYNN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:71 MDG
Mailing Address - Street 2:527 GOTT RD
Mailing Address - City:VANCE AFB
Mailing Address - State:OK
Mailing Address - Zip Code:73705-5105
Mailing Address - Country:US
Mailing Address - Phone:580-213-7909
Mailing Address - Fax:
Practice Address - Street 1:71 MDG
Practice Address - Street 2:527 GOTT RD
Practice Address - City:VANCE AFB
Practice Address - State:OK
Practice Address - Zip Code:73705-5105
Practice Address - Country:US
Practice Address - Phone:580-213-7909
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-17
Last Update Date:2009-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK55339164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse