Provider Demographics
NPI:1174833412
Name:BENSON, TRACI (LPN)
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:
Last Name:BENSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4795 WALFORD RD
Mailing Address - Street 2:APT # 15
Mailing Address - City:WARRENSVILLE HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44128-5125
Mailing Address - Country:US
Mailing Address - Phone:216-324-8286
Mailing Address - Fax:
Practice Address - Street 1:4795 WALFORD RD
Practice Address - Street 2:APT # 15
Practice Address - City:WARRENSVILLE HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44128-5125
Practice Address - Country:US
Practice Address - Phone:216-324-8286
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-20
Last Update Date:2010-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN138045164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse