Provider Demographics
NPI:1205891868
Name:NELSON JOHNSON, TRACI N (DC)
Entity type:Individual
Prefix:
First Name:TRACI
Middle Name:N
Last Name:NELSON JOHNSON
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2377 CUMBERLAND SQUARE DR
Mailing Address - Street 2:
Mailing Address - City:BETTENDORF
Mailing Address - State:IA
Mailing Address - Zip Code:52722-3251
Mailing Address - Country:US
Mailing Address - Phone:563-359-9541
Mailing Address - Fax:563-344-3914
Practice Address - Street 1:2377 CUMBERLAND SQUARE DR
Practice Address - Street 2:
Practice Address - City:BETTENDORF
Practice Address - State:IA
Practice Address - Zip Code:52722-3251
Practice Address - Country:US
Practice Address - Phone:563-359-9541
Practice Address - Fax:563-344-3914
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2017-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA731689454111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1186874Medicaid
IA48886OtherWELLMARK
IAI11498Medicare ID - Type Unspecified
IA1186874Medicaid