Provider Demographics
NPI:1629576624
Name:CUSTER, TRACY LYNN I
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:LYNN
Last Name:CUSTER
Suffix:I
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 1:311 E MARKET ST FL 3
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45801-4535
Mailing Address - Country:US
Mailing Address - Phone:419-222-4474
Mailing Address - Fax:
Practice Address - Street 1:105 PRIMROSE PL
Practice Address - Street 2:
Practice Address - City:SPENCERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45887-1252
Practice Address - Country:US
Practice Address - Phone:419-236-2755
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-25
Last Update Date:2018-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH161430164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse