Provider Demographics
NPI:1811619406
Name:JOHNSON, TRACEY (RN)
Entity type:Individual
Prefix:
First Name:TRACEY
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:E4340 130TH AVE
Mailing Address - Street 2:
Mailing Address - City:MENOMONIE
Mailing Address - State:WI
Mailing Address - Zip Code:54751-6728
Mailing Address - Country:US
Mailing Address - Phone:715-279-7757
Mailing Address - Fax:
Practice Address - Street 1:E4507 COUNTY ROAD C
Practice Address - Street 2:
Practice Address - City:DOWNSVILLE
Practice Address - State:WI
Practice Address - Zip Code:54735-5475
Practice Address - Country:US
Practice Address - Phone:715-279-7757
Practice Address - Fax:715-664-8196
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-12
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI163696-30163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty