Provider Demographics
NPI:1295295103
Name:FAHRENHOLZ, TRACI MARIE
Entity type:Individual
Prefix:
First Name:TRACI
Middle Name:MARIE
Last Name:FAHRENHOLZ
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 1:320 N 19TH ST
Mailing Address - Street 2:
Mailing Address - City:ORD
Mailing Address - State:NE
Mailing Address - Zip Code:68862-1351
Mailing Address - Country:US
Mailing Address - Phone:308-728-5013
Mailing Address - Fax:
Practice Address - Street 1:320 N 19TH ST
Practice Address - Street 2:
Practice Address - City:ORD
Practice Address - State:NE
Practice Address - Zip Code:68862-1351
Practice Address - Country:US
Practice Address - Phone:308-728-5013
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-25
Last Update Date:2019-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE45626163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE88-0005Medicaid