Healthcare Provider Details

I. General information

NPI: 1558806943
Provider Name (Legal Business Name): TRACY KENNEDY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: TRACY SAMS

II. Dates (important events)

Enumeration Date: 12/21/2016
Last Update Date: 12/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

234 GOODMAN ST
CINCINNATI OH
45219-2364
US

IV. Provider business mailing address

234 GOODMAN ST
CINCINNATI OH
45219-2364
US

V. Phone/Fax

Practice location:
  • Phone: 513-475-8787
  • Fax: 513-558-3136
Mailing address:
  • Phone: 513-475-8787
  • Fax: 513-558-3136

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN CNP 020307
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: