Provider Demographics
NPI:1356490064
Name:ALLEN, TRACY A
Entity Type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:A
Last Name:ALLEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1961 ROME GREENWICH RD
Mailing Address - Street 2:
Mailing Address - City:GREENWICH
Mailing Address - State:OH
Mailing Address - Zip Code:44837-9101
Mailing Address - Country:US
Mailing Address - Phone:419-929-9045
Mailing Address - Fax:
Practice Address - Street 1:1961 ROME GREENWICH RD
Practice Address - Street 2:
Practice Address - City:GREENWICH
Practice Address - State:OH
Practice Address - Zip Code:44837-9101
Practice Address - Country:US
Practice Address - Phone:419-929-9045
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN-089609164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2390970Medicaid