Provider Demographics
NPI:1467658518
Name:EICHENLAUB, TRICIA MAE (APRN)
Entity Type:Individual
Prefix:MRS
First Name:TRICIA
Middle Name:MAE
Last Name:EICHENLAUB
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:MS
Other - First Name:TRICIA
Other - Middle Name:MAE
Other - Last Name:FULLERTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:36 PEMBERTON CV
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-5514
Mailing Address - Country:US
Mailing Address - Phone:731-394-1145
Mailing Address - Fax:
Practice Address - Street 1:1050 CLINTON ST
Practice Address - Street 2:
Practice Address - City:IRONTON
Practice Address - State:OH
Practice Address - Zip Code:45638-2876
Practice Address - Country:US
Practice Address - Phone:731-394-1145
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-25
Last Update Date:2023-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA03038363LF0000X
KY3006716363LF0000X
OH12489-NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3127548Medicaid
KYK222320Medicare PIN
OH3127548Medicaid