Provider Demographics
NPI:1881929636
Name:KING, TRACI (NP)
Entity type:Individual
Prefix:
First Name:TRACI
Middle Name:
Last Name:KING
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:TRACI
Other - Middle Name:
Other - Last Name:GAYNIER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2142 N COVE BLVD
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43606-3895
Mailing Address - Country:US
Mailing Address - Phone:419-291-3627
Mailing Address - Fax:419-291-2142
Practice Address - Street 1:2142 N COVE BLVD
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43606-3895
Practice Address - Country:US
Practice Address - Phone:419-291-3627
Practice Address - Fax:419-291-2142
Is Sole Proprietor?:No
Enumeration Date:2009-10-13
Last Update Date:2010-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA.10902-NP363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner