Provider Demographics
NPI:1255843637
Name:PETTIT, TRACEY N (LPN)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:N
Last Name:PETTIT
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 1:4947 BLOOMFIELD DR APT S
Mailing Address - Street 2:
Mailing Address - City:TROTWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:45426-1656
Mailing Address - Country:US
Mailing Address - Phone:216-618-7558
Mailing Address - Fax:
Practice Address - Street 1:4947 BLOOMFIELD DR APT S
Practice Address - Street 2:
Practice Address - City:TROTWOOD
Practice Address - State:OH
Practice Address - Zip Code:45426-1656
Practice Address - Country:US
Practice Address - Phone:216-618-7558
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-25
Last Update Date:2017-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLPN.162637164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse