Healthcare Provider Details

I. General information

NPI: 1346003480
Provider Name (Legal Business Name): TRACIE COPELAND-SHUFF
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/01/2024
Last Update Date: 02/05/2024
Certification Date: 02/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 WALNUT ST
GREENVILLE OH
45331-1944
US

IV. Provider business mailing address

103 E PEPPERMINT ST
UNION CITY OH
45390-1912
US

V. Phone/Fax

Practice location:
  • Phone: 937-548-6842
  • Fax:
Mailing address:
  • Phone: 937-423-1256
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberAPS.004812
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: