Provider Demographics
NPI:1649887936
Name:TRACEY, LISA LUANNE
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:LUANNE
Last Name:TRACEY
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 1:4033 N EARLY RIDGE RD NE
Mailing Address - Street 2:
Mailing Address - City:MCCONNELSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43756-9730
Mailing Address - Country:US
Mailing Address - Phone:740-509-0233
Mailing Address - Fax:
Practice Address - Street 1:4033 N EARLY RIDGE RD NE
Practice Address - Street 2:
Practice Address - City:MCCONNELSVILLE
Practice Address - State:OH
Practice Address - Zip Code:43756-9730
Practice Address - Country:US
Practice Address - Phone:740-509-0233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-30
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No347C00000XTransportation ServicesPrivate Vehicle
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH6002310OtherDODD