Provider Demographics
NPI:1689697054
Name:KOTTENBROOK, TRACY LEE (LPN)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:LEE
Last Name:KOTTENBROOK
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 327
Mailing Address - Street 2:9350 WESTFALL ROAD
Mailing Address - City:FRANKFORT
Mailing Address - State:OH
Mailing Address - Zip Code:45628-0327
Mailing Address - Country:US
Mailing Address - Phone:740-998-6738
Mailing Address - Fax:740-998-6738
Practice Address - Street 1:9350 WESTFALL RD
Practice Address - Street 2:
Practice Address - City:FRANKFORT
Practice Address - State:OH
Practice Address - Zip Code:45628-0327
Practice Address - Country:US
Practice Address - Phone:740-998-6738
Practice Address - Fax:740-998-6738
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN 096321164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2129771Medicaid