Provider Demographics
NPI:1013630623
Name:HERNANDEZ, TRACEY L (LPN)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:L
Last Name:HERNANDEZ
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:TRACEY
Other - Middle Name:L
Other - Last Name:VELLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:527 N MERIDIAN RD
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44509-1227
Mailing Address - Country:US
Mailing Address - Phone:330-797-0070
Mailing Address - Fax:330-797-9146
Practice Address - Street 1:550 W CHALMERS AVE
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44511-1576
Practice Address - Country:US
Practice Address - Phone:330-797-0070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-20
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLPN.091625.MEDS-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse