Provider Demographics
NPI:1558802363
Name:CERUTTI-OWENS, TRACY L
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:L
Last Name:CERUTTI-OWENS
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 1:1330 E WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13210-1173
Mailing Address - Country:US
Mailing Address - Phone:315-426-5966
Mailing Address - Fax:
Practice Address - Street 1:1330 E WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-1173
Practice Address - Country:US
Practice Address - Phone:315-426-5966
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-13
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY259413-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse