MEDICARE: TRACI CAROL WILSON LPN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164W00000X	Licensed Practical Nurse	LPN.158944.MEDS-IV	OH

General Provider Information

NPI Number	:	1609365287
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TRACI CAROL WILSON LPN

Provider Business Mailing Address
First Line	:	65 SAINT FRANCIS AVE
Second Line	:
City	:	TIFFIN
State	:	OH
Zip	:	44883-3413
Country	:	US
Telephone Number	:	567-220-7018
Fax Number	:	567-220-7012

Provider Business Practice Location Address
First Line	:	65 SAINT FRANCIS AVE
Second Line	:
City	:	TIFFIN
State	:	OH
Zip	:	44883-3413
Country	:	US
Telephone Number	:	567-220-7018
Fax Number	:	567-220-7012

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/09/2018
Last Update Date	:	05/09/2018

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