Provider Demographics
NPI:1639436934
Name:LONGLEY, TRACI RENEE' (OWNER/ADMINISTRATOR)
Entity type:Individual
Prefix:
First Name:TRACI
Middle Name:RENEE'
Last Name:LONGLEY
Suffix:
Gender:F
Credentials:OWNER/ADMINISTRATOR
Other - Prefix:
Other - First Name:TRACI
Other - Middle Name:RENEE'
Other - Last Name:LONGLEY-EILAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:15595 LONGSPUR LN.
Mailing Address - Street 2:
Mailing Address - City:TERRELL
Mailing Address - State:TX
Mailing Address - Zip Code:75160
Mailing Address - Country:US
Mailing Address - Phone:972-563-9045
Mailing Address - Fax:972-563-9045
Practice Address - Street 1:15595 LONGSPUR LN.
Practice Address - Street 2:
Practice Address - City:TERRELL
Practice Address - State:TX
Practice Address - Zip Code:75160
Practice Address - Country:US
Practice Address - Phone:972-563-9045
Practice Address - Fax:972-563-9045
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-12
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker