Provider Demographics
NPI:1487181202
Name:COLLUM, TRACY
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:COLLUM
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 1:550 AMES ST
Mailing Address - Street 2:
Mailing Address - City:ELMORE
Mailing Address - State:OH
Mailing Address - Zip Code:43416-9736
Mailing Address - Country:US
Mailing Address - Phone:419-360-0764
Mailing Address - Fax:
Practice Address - Street 1:7980 WEBSTER DR
Practice Address - Street 2:
Practice Address - City:LAMBERTVILLE
Practice Address - State:MI
Practice Address - Zip Code:48144-9618
Practice Address - Country:US
Practice Address - Phone:419-360-0764
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-11
Last Update Date:2023-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAAPRN.CNP.020699363LG0600X
OHAPRN.CNP.020699363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology