Provider Demographics
NPI:1629575022
Name:STANTON, TRACY (LPN)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:STANTON
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:PO BOX 153
Mailing Address - Street 2:
Mailing Address - City:TROUT CREEK
Mailing Address - State:NY
Mailing Address - Zip Code:13847-0153
Mailing Address - Country:US
Mailing Address - Phone:607-865-3180
Mailing Address - Fax:
Practice Address - Street 1:7278 STATE HIGHWAY 206
Practice Address - Street 2:
Practice Address - City:SIDNEY CENTER
Practice Address - State:NY
Practice Address - Zip Code:13847
Practice Address - Country:US
Practice Address - Phone:604-865-3180
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-11
Last Update Date:2018-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY250450164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY443830784OtherDRIVERS LICENSE