Healthcare Provider Details

I. General information

NPI: 1558069690
Provider Name (Legal Business Name): TRACY CORTEZAVAD APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2023
Last Update Date: 04/26/2023
Certification Date: 04/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3567 RESERVE COMMONS DR SUITE 100
MEDINA OH
44256
US

IV. Provider business mailing address

3593 MEDINA RD STE 181
MEDINA OH
44256-8182
US

V. Phone/Fax

Practice location:
  • Phone: 330-536-3746
  • Fax:
Mailing address:
  • Phone: 330-536-3746
  • Fax: 419-696-8819

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN.368860
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN.CNP.0033297
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: