Provider Demographics
NPI:1588634976
Name:EVANS-ELLACOTT, TRACI EILEEN (CNP)
Entity Type:Individual
Prefix:MRS
First Name:TRACI
Middle Name:EILEEN
Last Name:EVANS-ELLACOTT
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29325 HEALTH CAMPUS DR
Mailing Address - Street 2:SUITE 3
Mailing Address - City:WESTLAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44145-8201
Mailing Address - Country:US
Mailing Address - Phone:440-414-9412
Mailing Address - Fax:440-414-9059
Practice Address - Street 1:125 E BROAD ST
Practice Address - Street 2:SUITE 305
Practice Address - City:ELYRIA
Practice Address - State:OH
Practice Address - Zip Code:44035-6400
Practice Address - Country:US
Practice Address - Phone:440-414-9100
Practice Address - Fax:440-322-3454
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2011-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNP-06543363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
500022799OtherRAILROAD MEDICARE
OH000000342754OtherANTHEM
OH2284004Medicaid
500022799OtherRAILROAD MEDICARE
P46379Medicare UPIN