Provider Demographics
NPI:1275332561
Name:VAN BRIESEN, TRACE THOMAS
Entity type:Individual
Prefix:
First Name:TRACE
Middle Name:THOMAS
Last Name:VAN BRIESEN
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7609 S 101ST ST
Mailing Address - Street 2:
Mailing Address - City:LA VISTA
Mailing Address - State:NE
Mailing Address - Zip Code:68128-8261
Mailing Address - Country:US
Mailing Address - Phone:402-981-5547
Mailing Address - Fax:
Practice Address - Street 1:7609 S 101ST ST
Practice Address - Street 2:
Practice Address - City:LA VISTA
Practice Address - State:NE
Practice Address - Zip Code:68128-8261
Practice Address - Country:US
Practice Address - Phone:402-981-5547
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-10
Last Update Date:2025-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide