Provider Demographics
NPI:1255903084
Name:MAIN, TRACI LAVERN (RN, DHS)
Entity type:Individual
Prefix:
First Name:TRACI
Middle Name:LAVERN
Last Name:MAIN
Suffix:
Gender:F
Credentials:RN, DHS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:871 PACER CT
Mailing Address - Street 2:
Mailing Address - City:CORYDON
Mailing Address - State:IN
Mailing Address - Zip Code:47112
Mailing Address - Country:US
Mailing Address - Phone:812-738-0317
Mailing Address - Fax:
Practice Address - Street 1:871 PACER CT
Practice Address - Street 2:
Practice Address - City:CORYDON
Practice Address - State:IN
Practice Address - Zip Code:47112
Practice Address - Country:US
Practice Address - Phone:812-738-0317
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-12
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28256382A364SL0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SL0600XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistLong-Term Care