Healthcare Provider Details

I. General information

NPI: 1558054536
Provider Name (Legal Business Name): TRACEY LEE VIEN AGNP RN PHN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/26/2023
Last Update Date: 05/26/2023
Certification Date: 05/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4867 W SUNSET BLVD
LOS ANGELES CA
90027-5969
US

IV. Provider business mailing address

2423 CHARLOTTE AVE
ROSEMEAD CA
91770-3628
US

V. Phone/Fax

Practice location:
  • Phone: 323-783-7156
  • Fax:
Mailing address:
  • Phone: 626-623-8602
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number95094588
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number95094588
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number95021281
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: