Provider Demographics
NPI:1831624956
Name:NICKELSON, TRACI LYNN (CNP-BC)
Entity type:Individual
Prefix:MRS
First Name:TRACI
Middle Name:LYNN
Last Name:NICKELSON
Suffix:
Gender:F
Credentials:CNP-BC
Other - Prefix:
Other - First Name:TRACI
Other - Middle Name:LYNN
Other - Last Name:BYERLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:802 SPENCER ST
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43609-3030
Mailing Address - Country:US
Mailing Address - Phone:419-203-3252
Mailing Address - Fax:
Practice Address - Street 1:14121 PARKE LONG CT STE 201
Practice Address - Street 2:
Practice Address - City:CHANTILLY
Practice Address - State:VA
Practice Address - Zip Code:20151-1647
Practice Address - Country:US
Practice Address - Phone:855-247-1940
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-26
Last Update Date:2017-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.020218363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily