Provider Demographics
NPI:1093526535
Name:MACK, TRACY YARNELL
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:YARNELL
Last Name:MACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1807 PROVINCIAL CT
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45214-1319
Mailing Address - Country:US
Mailing Address - Phone:513-345-0800
Mailing Address - Fax:
Practice Address - Street 1:1807 PROVINCIAL CT
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45214-1319
Practice Address - Country:US
Practice Address - Phone:513-345-0800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-15
Last Update Date:2025-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide