Healthcare Provider Details

I. General information

NPI: 1871893222
Provider Name (Legal Business Name): TRACEY LYNN CHILDRESS MSN, FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2010
Last Update Date: 06/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 HOSPITAL DR SUITE 103
BARNESVILLE OH
43713-1098
US

IV. Provider business mailing address

62370 LYNDALE AVE
BARNESVILLE OH
43713-9691
US

V. Phone/Fax

Practice location:
  • Phone: 740-425-5190
  • Fax:
Mailing address:
  • Phone: 740-425-1878
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCOA. 11436-NP
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: