Provider Demographics
NPI:1891039574
Name:KILMARTIN, TRACI L (LP, CP)
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:L
Last Name:KILMARTIN
Suffix:
Gender:F
Credentials:LP, CP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2108 E 3RD ST STE 100
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37404-2623
Mailing Address - Country:US
Mailing Address - Phone:423-493-2395
Mailing Address - Fax:423-493-2368
Practice Address - Street 1:2108 E 3RD ST
Practice Address - Street 2:SUITE 100
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37404-2600
Practice Address - Country:US
Practice Address - Phone:423-267-0466
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-19
Last Update Date:2015-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPRO183224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNPRO183OtherTN PROSTHETIS LICENSE