Provider Demographics
NPI:1639743461
Name:PATTON, TRACY ANN (LPN)
Entity Type:Individual
Prefix:MS
First Name:TRACY
Middle Name:ANN
Last Name:PATTON
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 1:374 E GRAYSON ST
Mailing Address - Street 2:
Mailing Address - City:HILLSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24343-1417
Mailing Address - Country:US
Mailing Address - Phone:276-237-1328
Mailing Address - Fax:
Practice Address - Street 1:140 LARKSPUR LN STE D
Practice Address - Street 2:
Practice Address - City:GALAX
Practice Address - State:VA
Practice Address - Zip Code:24333-2753
Practice Address - Country:US
Practice Address - Phone:276-236-6341
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-17
Last Update Date:2021-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0002085172164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1538208566Medicaid