Provider Demographics
NPI:1326700030
Name:NDIYOB, TRACY NESIRI (LPN)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:NESIRI
Last Name:NDIYOB
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 1:2018 VAN KARAJAN DR
Mailing Address - Street 2:
Mailing Address - City:RANCHO PALOS VERDES
Mailing Address - State:CA
Mailing Address - Zip Code:90275
Mailing Address - Country:US
Mailing Address - Phone:424-254-6604
Mailing Address - Fax:
Practice Address - Street 1:2018 VAN KARAJAN DR
Practice Address - Street 2:
Practice Address - City:RANCHO PALOS VERDES
Practice Address - State:CA
Practice Address - Zip Code:90275
Practice Address - Country:US
Practice Address - Phone:424-254-6604
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-10
Last Update Date:2021-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA716801164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse