Provider Demographics
NPI:1225381833
Name:PHILLIPS, TRACI N (CNP)
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:N
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3000 MACK RD
Mailing Address - Street 2:STE 120
Mailing Address - City:FAIRFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45014-5335
Mailing Address - Country:US
Mailing Address - Phone:513-682-6975
Mailing Address - Fax:513-682-6976
Practice Address - Street 1:3000 MACK RD
Practice Address - Street 2:STE 120
Practice Address - City:FAIRFIELD
Practice Address - State:OH
Practice Address - Zip Code:45014-5335
Practice Address - Country:US
Practice Address - Phone:513-682-6975
Practice Address - Fax:513-682-6976
Is Sole Proprietor?:No
Enumeration Date:2012-10-19
Last Update Date:2013-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA.13933-NP363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0079955Medicaid
OHH151181Medicare PIN