Provider Demographics
NPI:1861807521
Name:DENISE, TRACY LEE (LPN)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:LEE
Last Name:DENISE
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 1:88 EAST ST
Mailing Address - Street 2:
Mailing Address - City:HONEOYE FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:14472-1229
Mailing Address - Country:US
Mailing Address - Phone:585-317-9810
Mailing Address - Fax:888-294-7667
Practice Address - Street 1:88 EAST ST
Practice Address - Street 2:
Practice Address - City:HONEOYE FALLS
Practice Address - State:NY
Practice Address - Zip Code:14472-1229
Practice Address - Country:US
Practice Address - Phone:585-317-9810
Practice Address - Fax:888-294-7667
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-20
Last Update Date:2014-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY243195-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse