Provider Demographics
NPI:1760727895
Name:SELBY, TRACI LEA (LPN)
Entity Type:Individual
Prefix:MS
First Name:TRACI
Middle Name:LEA
Last Name:SELBY
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 1:5613 GENDER RD
Mailing Address - Street 2:
Mailing Address - City:CANAL WINCHESTER
Mailing Address - State:OH
Mailing Address - Zip Code:43110-7702
Mailing Address - Country:US
Mailing Address - Phone:614-569-1017
Mailing Address - Fax:
Practice Address - Street 1:5613 GENDER RD
Practice Address - Street 2:
Practice Address - City:CANAL WINCHESTER
Practice Address - State:OH
Practice Address - Zip Code:43110-7702
Practice Address - Country:US
Practice Address - Phone:614-569-1017
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-29
Last Update Date:2012-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH139719164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse