Provider Demographics
NPI:1184083883
Name:MATTOX, TRACI (CNA)
Entity type:Individual
Prefix:
First Name:TRACI
Middle Name:
Last Name:MATTOX
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 1:903 S ADAMS ST
Mailing Address - Street 2:
Mailing Address - City:RITZVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:99169-2227
Mailing Address - Country:US
Mailing Address - Phone:509-659-5408
Mailing Address - Fax:509-659-0522
Practice Address - Street 1:903 S ADAMS ST
Practice Address - Street 2:
Practice Address - City:RITZVILLE
Practice Address - State:WA
Practice Address - Zip Code:99169-2227
Practice Address - Country:US
Practice Address - Phone:509-659-5408
Practice Address - Fax:509-659-0522
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-23
Last Update Date:2016-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WANC10083060374700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374700000XNursing Service Related ProvidersTechnician