Healthcare Provider Details

I. General information

NPI: 1093880833
Provider Name (Legal Business Name): CHRIS J TREACE RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

909 E STATE BLVD
FORT WAYNE IN
46805-3404
US

IV. Provider business mailing address

909 E STATE BLVD
FORT WAYNE IN
46805-3404
US

V. Phone/Fax

Practice location:
  • Phone: 260-481-2700
  • Fax: 260-481-2717
Mailing address:
  • Phone: 260-481-2700
  • Fax: 260-481-2717

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number28123633A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: