Healthcare Provider Details

I. General information

NPI: 1750003745
Provider Name (Legal Business Name): TRACY CHILDERS BARTZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2022
Last Update Date: 05/23/2024
Certification Date: 05/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

298 TRICORN RD
DANVILLE WV
25053-7148
US

IV. Provider business mailing address

298 TRICORN RD
DANVILLE WV
25053-7148
US

V. Phone/Fax

Practice location:
  • Phone: 304-369-1385
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number246737
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number246737
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: