Provider Demographics
NPI:1760931604
Name:PRIMUS-BLACKMON, TRACY
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:PRIMUS-BLACKMON
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:TRACY
Other - Middle Name:
Other - Last Name:PRIMUS-BLACKMON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPN
Mailing Address - Street 1:534 MERRIMAN RD
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44303-1644
Mailing Address - Country:US
Mailing Address - Phone:330-761-2665
Mailing Address - Fax:330-761-2661
Practice Address - Street 1:985 GORGE BLVD
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44310-2407
Practice Address - Country:US
Practice Address - Phone:330-761-2665
Practice Address - Fax:330-761-2661
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-03
Last Update Date:2016-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLPN.143750.MEDS-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse