Provider Demographics
NPI:1629245998
Name:PHILLIPS, TRACY LYNN (LPN)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:LYNN
Last Name:PHILLIPS
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 1:5620 W BIRCH HARBOR DR
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-9430
Mailing Address - Country:US
Mailing Address - Phone:907-775-2800
Mailing Address - Fax:
Practice Address - Street 1:5620 W BIRCH HARBOR DR
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-9430
Practice Address - Country:US
Practice Address - Phone:907-775-2800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-14
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK5250164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse