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General NPI Number Information
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NPI Number | 1962038018
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Entity Type | Individual
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Provider Name | TRACEE JON DAHLKE NURSE PRACTITIONER
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Gender | Female
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Dates
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Enumeration Date | 03/20/2020
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Last Update Date | 03/16/2022
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Provider Practice Location Address
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Address Line | 320 SW 2ND ST
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City | CORVALLIS
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State | OR
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Zip | 97333-4632
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Country | US
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Telephone | 541-207-3709
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Fax |
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Provider Business Mailing Address
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Address Line | 32949 WILDROSE DR
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City | TANGENT
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State | OR
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Zip | 97389-9518
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Country | US
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Telephone | 808-265-5970
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LS0200X
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Taxonomy Name | School Nurse Practitioner
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License Number | 201509445RN
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License Number State | OR
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Taxonomy #2
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 202202434NP-PP
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License Number State | OR
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