Healthcare Provider Details

I. General information

NPI: 1942453113
Provider Name (Legal Business Name): TRACY DICKERSON CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2008
Last Update Date: 02/04/2020
Certification Date: 02/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 BAY PARK DR
OREGON OH
43616-4920
US

IV. Provider business mailing address

1 SEAGATE # 800
TOLEDO OH
43604-1558
US

V. Phone/Fax

Practice location:
  • Phone: 419-690-7900
  • Fax: 419-697-7726
Mailing address:
  • Phone: 419-690-7900
  • Fax: 419-697-7726

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN219439
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAPRN.CRNA.10348
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: