Healthcare Provider Details

I. General information

NPI: 1669292132
Provider Name (Legal Business Name): TRACI MICHELL ALLEN RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2024
Last Update Date: 10/10/2024
Certification Date: 10/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 BODIN CIR
FAIRFIELD CA
94535-1809
US

IV. Provider business mailing address

550 WIEGAND WAY
DIXON CA
95620-4522
US

V. Phone/Fax

Practice location:
  • Phone: 707-423-7331
  • Fax:
Mailing address:
  • Phone: 850-826-1136
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number9228192
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: