Provider Demographics
NPI:1992044796
Name:KING, TRACY (LPN)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:KING
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 587
Mailing Address - Street 2:
Mailing Address - City:ADDYSTON
Mailing Address - State:OH
Mailing Address - Zip Code:45001
Mailing Address - Country:US
Mailing Address - Phone:859-307-6364
Mailing Address - Fax:
Practice Address - Street 1:587 BOX LANE
Practice Address - Street 2:
Practice Address - City:ADDYSTON
Practice Address - State:OH
Practice Address - Zip Code:45001
Practice Address - Country:US
Practice Address - Phone:859-307-6364
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-14
Last Update Date:2013-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN 83131164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse