Provider Demographics
NPI:1558054536
Name:VIEN, TRACEY LEE (AGNP RN PHN)
Entity type:Individual
Prefix:
First Name:TRACEY
Middle Name:LEE
Last Name:VIEN
Suffix:
Gender:F
Credentials:AGNP RN PHN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2423 CHARLOTTE AVE
Mailing Address - Street 2:
Mailing Address - City:ROSEMEAD
Mailing Address - State:CA
Mailing Address - Zip Code:91770-3628
Mailing Address - Country:US
Mailing Address - Phone:626-623-8602
Mailing Address - Fax:
Practice Address - Street 1:4867 W SUNSET BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-5969
Practice Address - Country:US
Practice Address - Phone:323-783-7156
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-26
Last Update Date:2023-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95094588163WC0400X, 163WE0003X
CA95021281363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management
No163WE0003XNursing Service ProvidersRegistered NurseEmergency
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care