Provider Demographics
NPI:1922325240
Name:OWENS, TRACIE LYNETTE
Entity Type:Individual
Prefix:MISS
First Name:TRACIE
Middle Name:LYNETTE
Last Name:OWENS
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 1:3112 SURF AVE
Mailing Address - Street 2:
Mailing Address - City:LORAIN
Mailing Address - State:OH
Mailing Address - Zip Code:44053-1545
Mailing Address - Country:US
Mailing Address - Phone:440-453-2116
Mailing Address - Fax:
Practice Address - Street 1:3112 SURF AVE
Practice Address - Street 2:
Practice Address - City:LORAIN
Practice Address - State:OH
Practice Address - Zip Code:44053-1545
Practice Address - Country:US
Practice Address - Phone:440-453-2116
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-26
Last Update Date:2017-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN 120791 IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse