Provider Demographics
NPI:1619523776
Name:BLAKSTAD, TRACY
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:BLAKSTAD
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 1:1024 BRINKMAN ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89138-6086
Mailing Address - Country:US
Mailing Address - Phone:702-713-3191
Mailing Address - Fax:
Practice Address - Street 1:6615 S EASTERN AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-3921
Practice Address - Country:US
Practice Address - Phone:702-722-6200
Practice Address - Fax:702-722-6202
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-14
Last Update Date:2019-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV251E00000XOtherHOME HEALTH