Provider Demographics
NPI:1386886596
Name:GLYNN, TRACI LEE (LPN)
Entity type:Individual
Prefix:
First Name:TRACI
Middle Name:LEE
Last Name:GLYNN
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:237 BIRCH DR
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49445-2213
Mailing Address - Country:US
Mailing Address - Phone:231-744-2086
Mailing Address - Fax:
Practice Address - Street 1:237 BIRCH DR
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49445-2213
Practice Address - Country:US
Practice Address - Phone:231-744-2086
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-02
Last Update Date:2009-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703098560164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse