Provider Demographics
NPI:1669902128
Name:LONG, TRACY DINAH
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:DINAH
Last Name:LONG
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 1:2120 SW 84TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73159-6102
Mailing Address - Country:US
Mailing Address - Phone:405-505-6205
Mailing Address - Fax:
Practice Address - Street 1:2629 W I 44 SERVICE RD STE 202
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-3762
Practice Address - Country:US
Practice Address - Phone:405-605-1865
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-18
Last Update Date:2017-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK37V239421202376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide