Healthcare Provider Details

I. General information

NPI: 1164661096
Provider Name (Legal Business Name): TRACI LYNN JOHNSON LVN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2009
Last Update Date: 02/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

71 MDG 527 GOTT RD
VANCE AFB OK
73705-5105
US

IV. Provider business mailing address

71 MDG 527 GOTT RD
VANCE AFB OK
73705-5105
US

V. Phone/Fax

Practice location:
  • Phone: 580-213-7909
  • Fax:
Mailing address:
  • Phone: 580-213-7909
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number55339
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: