Healthcare Provider Details

I. General information

NPI: 1568778892
Provider Name (Legal Business Name): TRACEY W YEAMAN CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2010
Last Update Date: 08/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

142 S MAIN ST
DANVILLE VA
24541-2922
US

IV. Provider business mailing address

142 S MAIN ST
DANVILLE VA
24541-2922
US

V. Phone/Fax

Practice location:
  • Phone: 434-799-2375
  • Fax:
Mailing address:
  • Phone: 434-799-2100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number71986
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number0001170056
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: