MEDICARE: TRACY DINAH LONG

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	376K00000X	Nurse's Aide	37V239421202	OK

General Provider Information

NPI Number	:	1669902128
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TRACY DINAH LONG

Provider Business Mailing Address
First Line	:	2120 SW 84TH ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73159-6102
Country	:	US
Telephone Number	:	405-505-6205
Fax Number	:

Provider Business Practice Location Address
First Line	:	2629 W I 44 SERVICE RD STE 202
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73112-3762
Country	:	US
Telephone Number	:	405-605-1865
Fax Number	:

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

Provider Enumeration Date	:	06/18/2017
Last Update Date	:	06/18/2017

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