Provider Demographics
NPI:1922779909
Name:BICKNELL, TRACY LYNN
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:LYNN
Last Name:BICKNELL
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 1:20907 JO MARIE WAY
Mailing Address - Street 2:
Mailing Address - City:CALLAWAY
Mailing Address - State:MD
Mailing Address - Zip Code:20620-2322
Mailing Address - Country:US
Mailing Address - Phone:301-437-6588
Mailing Address - Fax:
Practice Address - Street 1:20907 JO MARIE WAY
Practice Address - Street 2:
Practice Address - City:CALLAWAY
Practice Address - State:MD
Practice Address - Zip Code:20620-2322
Practice Address - Country:US
Practice Address - Phone:301-437-6588
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-21
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001216990163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse