Provider Demographics
NPI:1538671359
Name:WILSON, TRACEY (RCFE)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:RCFE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:864 GRAND AVE # 802
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92109-3906
Mailing Address - Country:US
Mailing Address - Phone:619-357-6472
Mailing Address - Fax:
Practice Address - Street 1:639 S GREGORY ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92113-2617
Practice Address - Country:US
Practice Address - Phone:619-693-9080
Practice Address - Fax:619-393-2177
Is Sole Proprietor?:No
Enumeration Date:2017-11-02
Last Update Date:2017-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6029334740376G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376G00000XNursing Service Related ProvidersNursing Home Administrator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA6029334740OtherRCFE ADMINISTRATOR CERTIFICATION