Provider Demographics
NPI:1609365287
Name:WILSON, TRACI CAROL (LPN)
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:CAROL
Last Name:WILSON
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 1:65 SAINT FRANCIS AVE
Mailing Address - Street 2:
Mailing Address - City:TIFFIN
Mailing Address - State:OH
Mailing Address - Zip Code:44883-3413
Mailing Address - Country:US
Mailing Address - Phone:567-220-7018
Mailing Address - Fax:567-220-7012
Practice Address - Street 1:65 SAINT FRANCIS AVE
Practice Address - Street 2:
Practice Address - City:TIFFIN
Practice Address - State:OH
Practice Address - Zip Code:44883-3413
Practice Address - Country:US
Practice Address - Phone:567-220-7018
Practice Address - Fax:567-220-7012
Is Sole Proprietor?:No
Enumeration Date:2018-05-09
Last Update Date:2018-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLPN.158944.MEDS-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse