Provider Demographics
NPI:1255391892
Name:ROGERS, TRACIE NICHELLE
Entity type:Individual
Prefix:MRS
First Name:TRACIE
Middle Name:NICHELLE
Last Name:ROGERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:652 CHUCK WAGON DR
Mailing Address - Street 2:
Mailing Address - City:GALLOWAY
Mailing Address - State:OH
Mailing Address - Zip Code:43119-8319
Mailing Address - Country:US
Mailing Address - Phone:614-378-1522
Mailing Address - Fax:614-378-1522
Practice Address - Street 1:652 CHUCK WAGON DR
Practice Address - Street 2:
Practice Address - City:GALLOWAY
Practice Address - State:OH
Practice Address - Zip Code:43119-8319
Practice Address - Country:US
Practice Address - Phone:614-378-1522
Practice Address - Fax:614-378-1522
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-27
Last Update Date:2011-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
374U00000X
OHRN364564163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health
No374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3128243Medicaid