Provider Demographics
NPI:1174814313
Name:BULOW, TRACI L (RN)
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:L
Last Name:BULOW
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 N WISCONSIN ST
Mailing Address - Street 2:
Mailing Address - City:ELKHORN
Mailing Address - State:WI
Mailing Address - Zip Code:53121-1118
Mailing Address - Country:US
Mailing Address - Phone:262-723-7736
Mailing Address - Fax:
Practice Address - Street 1:501 N WISCONSIN ST
Practice Address - Street 2:
Practice Address - City:ELKHORN
Practice Address - State:WI
Practice Address - Zip Code:53121-1118
Practice Address - Country:US
Practice Address - Phone:262-723-7736
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-21
Last Update Date:2011-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI162541-030163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse