Provider Demographics
NPI:1386946556
Name:SPAFFORD, TRACEY DYAN (RN)
Entity type:Individual
Prefix:MS
First Name:TRACEY
Middle Name:DYAN
Last Name:SPAFFORD
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44 NICOLE DR
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:KY
Mailing Address - Zip Code:41051-7317
Mailing Address - Country:US
Mailing Address - Phone:859-359-0191
Mailing Address - Fax:
Practice Address - Street 1:1 MEDICAL VILLAGE DR
Practice Address - Street 2:
Practice Address - City:EDGEWOOD
Practice Address - State:KY
Practice Address - Zip Code:41017-3403
Practice Address - Country:US
Practice Address - Phone:859-341-7246
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-22
Last Update Date:2012-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1118099163W00000X
OHRN 322985163W00000X
KY085937367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
611077369 1295716850OtherHEALTHNET
IN201008860Medicaid
OH3125620Medicaid
000000702876OtherANTHEM
KY7100148650Medicaid
$$$$$$$$$00OtherBUREAU OF WORKERS COMP
IN201008860Medicaid
KY7100148650Medicaid
KYP00956938Medicare PIN
8249061Medicare PIN