Healthcare Provider Details

I. General information

NPI: 1821051012
Provider Name (Legal Business Name): TRACEY M. BUTLER CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TRACEY M. FOCHT-TILTON

II. Dates (important events)

Enumeration Date: 04/09/2006
Last Update Date: 04/25/2023
Certification Date: 04/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8401 MARKET ST
YOUNGSTOWN OH
44512
US

IV. Provider business mailing address

4135 BOARDMAN CANFIELD RD STE 101
CANFIELD OH
44406-9803
US

V. Phone/Fax

Practice location:
  • Phone: 330-729-2929
  • Fax:
Mailing address:
  • Phone: 330-286-5330
  • Fax: 330-286-5396

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number1103844
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN.395377
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: