Provider Demographics
NPI:1396040960
Name:HAMRE, TRACYE A
Entity Type:Individual
Prefix:
First Name:TRACYE
Middle Name:A
Last Name:HAMRE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TRACYE
Other - Middle Name:A
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CENA
Mailing Address - Street 1:12840 OAK PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48237-2125
Mailing Address - Country:US
Mailing Address - Phone:248-219-4069
Mailing Address - Fax:
Practice Address - Street 1:12840 OAK PARK BLVD
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:MI
Practice Address - Zip Code:48237-2125
Practice Address - Country:US
Practice Address - Phone:248-219-4069
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-12
Last Update Date:2011-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI230013060550107376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide