Healthcare Provider Details

I. General information

NPI: 1689697054
Provider Name (Legal Business Name): TRACY LEE KOTTENBROOK L.P.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9350 WESTFALL RD
FRANKFORT OH
45628-0327
US

IV. Provider business mailing address

PO BOX 327 9350 WESTFALL ROAD
FRANKFORT OH
45628-0327
US

V. Phone/Fax

Practice location:
  • Phone: 740-998-6738
  • Fax: 740-998-6738
Mailing address:
  • Phone: 740-998-6738
  • Fax: 740-998-6738

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberPN 096321
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: