Provider Demographics
NPI:1649488891
Name:TRAYLOR, TRACY EVETTE (LPN)
Entity type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:EVETTE
Last Name:TRAYLOR
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3788 MAYFIELD RD
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND HTS
Mailing Address - State:OH
Mailing Address - Zip Code:44121-1756
Mailing Address - Country:US
Mailing Address - Phone:216-691-3752
Mailing Address - Fax:216-691-3752
Practice Address - Street 1:3788 MAYFIELD RD
Practice Address - Street 2:
Practice Address - City:CLEVELAND HTS
Practice Address - State:OH
Practice Address - Zip Code:44121-1756
Practice Address - Country:US
Practice Address - Phone:216-691-3752
Practice Address - Fax:216-691-3752
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN104042164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2229761Medicaid