Healthcare Provider Details

I. General information

NPI: 1043554900
Provider Name (Legal Business Name): TRACY DAVIS LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/16/2012
Last Update Date: 09/26/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16601 NE 80TH ST #404
REDMOND WA
98052-6643
US

IV. Provider business mailing address

PO BOX 2803
REDMOND WA
98073-2803
US

V. Phone/Fax

Practice location:
  • Phone: 425-496-4354
  • Fax:
Mailing address:
  • Phone: 425-496-4354
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberLP00057085
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: