Healthcare Provider Details

I. General information

NPI: 1720610082
Provider Name (Legal Business Name): TRACEY LYNN RUSNAK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2020
Last Update Date: 03/09/2021
Certification Date: 03/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 EDGEWOOD DRIVE EXT
TRANSFER PA
16154-1817
US

IV. Provider business mailing address

100 SHENANGO AVE
SHARON PA
16146-1503
US

V. Phone/Fax

Practice location:
  • Phone: 724-962-3553
  • Fax: 724-962-3630
Mailing address:
  • Phone: 724-962-3553
  • Fax: 724-962-3630

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN.CNP.026275
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: