Healthcare Provider Details

I. General information

NPI: 1366753345
Provider Name (Legal Business Name): TRACIE SUE BAKEWELL CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2010
Last Update Date: 08/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

194 E LONGVIEW AVE
COLUMBUS OH
43202-1236
US

IV. Provider business mailing address

194 E LONGVIEW AVE
COLUMBUS OH
43202-1236
US

V. Phone/Fax

Practice location:
  • Phone: 614-226-7388
  • Fax:
Mailing address:
  • Phone: 614-226-7388
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number15353
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number350181
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: