Provider Demographics
NPI:1740524289
Name:NANCE, TRACY L (MA,CCC-SP)
Entity type:Individual
Prefix:MS
First Name:TRACY
Middle Name:L
Last Name:NANCE
Suffix:
Gender:F
Credentials:MA,CCC-SP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1537 24TH AVE
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-6379
Mailing Address - Country:US
Mailing Address - Phone:724-331-4534
Mailing Address - Fax:
Practice Address - Street 1:1537 24TH AVE
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-6379
Practice Address - Country:US
Practice Address - Phone:724-331-4534
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-22
Last Update Date:2020-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI1165235Z00000X
WA61096683235Z00000X
ID2858235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist