Provider Demographics
NPI:1962038018
Name:DAHLKE, TRACEE JON (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:TRACEE
Middle Name:JON
Last Name:DAHLKE
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:TRACEE
Other - Middle Name:JON
Other - Last Name:SCOTT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:32949 WILDROSE DR
Mailing Address - Street 2:
Mailing Address - City:TANGENT
Mailing Address - State:OR
Mailing Address - Zip Code:97389-9518
Mailing Address - Country:US
Mailing Address - Phone:808-265-5970
Mailing Address - Fax:
Practice Address - Street 1:320 SW 2ND ST
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97333-4632
Practice Address - Country:US
Practice Address - Phone:541-207-3709
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-20
Last Update Date:2022-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201509445RN363LS0200X
OR202202434NP-PP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LS0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerSchool