Provider Demographics
NPI:1255692638
Name:JOHNSON, TRACY DARNELLE (RN)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:DARNELLE
Last Name:JOHNSON
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 1:985 IRVIN SHOOTS RD E
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:OH
Mailing Address - Zip Code:43302-9739
Mailing Address - Country:US
Mailing Address - Phone:740-225-5765
Mailing Address - Fax:
Practice Address - Street 1:985 IRVIN SHOOTS RD E
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:OH
Practice Address - Zip Code:43302-9739
Practice Address - Country:US
Practice Address - Phone:740-225-5765
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-01
Last Update Date:2012-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN363284163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse