Provider Demographics
NPI:1538313101
Name:MARSHALL, TRACY JONES (LPN)
Entity Type:Individual
Prefix:MS
First Name:TRACY
Middle Name:JONES
Last Name:MARSHALL
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 1:219 BLUEBIRD LN
Mailing Address - Street 2:
Mailing Address - City:PERRY
Mailing Address - State:GA
Mailing Address - Zip Code:31069-9389
Mailing Address - Country:US
Mailing Address - Phone:478-988-1222
Mailing Address - Fax:478-988-1241
Practice Address - Street 1:940 HIGHWAY 96 STE A
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31088-2587
Practice Address - Country:US
Practice Address - Phone:478-988-1222
Practice Address - Fax:478-988-1241
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-10
Last Update Date:2008-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA056838164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse