Provider Demographics
NPI:1851759914
Name:SMITH, TRACEY LYN
Entity Type:Individual
Prefix:MRS
First Name:TRACEY
Middle Name:LYN
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1212 FAUSSETT RD
Mailing Address - Street 2:
Mailing Address - City:HOWELL
Mailing Address - State:MI
Mailing Address - Zip Code:48855-7205
Mailing Address - Country:US
Mailing Address - Phone:313-443-3132
Mailing Address - Fax:
Practice Address - Street 1:1212 FAUSSETT RD
Practice Address - Street 2:
Practice Address - City:HOWELL
Practice Address - State:MI
Practice Address - Zip Code:48855-7205
Practice Address - Country:US
Practice Address - Phone:313-443-3132
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-04
Last Update Date:2016-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIS530802564261172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver