Provider Demographics
NPI:1760030977
Name:ANDERSON, TRACI CATHLEEN (CNA)
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:CATHLEEN
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:142 JOHN BROWN FARM CT
Mailing Address - Street 2:
Mailing Address - City:HARPERS FERRY
Mailing Address - State:WV
Mailing Address - Zip Code:25425-5723
Mailing Address - Country:US
Mailing Address - Phone:703-220-0317
Mailing Address - Fax:
Practice Address - Street 1:544 S SEMINARY ST
Practice Address - Street 2:
Practice Address - City:CHARLES TOWN
Practice Address - State:WV
Practice Address - Zip Code:25414-1347
Practice Address - Country:US
Practice Address - Phone:304-839-1262
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-30
Last Update Date:2019-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider