Provider Demographics
NPI:1952063059
Name:PROSSER, TRACY SHMAR (CNA)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:SHMAR
Last Name:PROSSER
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24875 NOVI RD UNIT 1344
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48376-7750
Mailing Address - Country:US
Mailing Address - Phone:313-808-0308
Mailing Address - Fax:
Practice Address - Street 1:47059 MANHATTAN CIR
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48374-1832
Practice Address - Country:US
Practice Address - Phone:313-808-0308
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-06
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIMI000054621376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide