Provider Demographics
NPI:1912669821
Name:KISH, TRACY
Entity type:Individual
Prefix:MISS
First Name:TRACY
Middle Name:
Last Name:KISH
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 1:15546 MEYER AVE
Mailing Address - Street 2:
Mailing Address - City:ALLEN PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48101-2744
Mailing Address - Country:US
Mailing Address - Phone:313-657-7762
Mailing Address - Fax:
Practice Address - Street 1:3850 2ND ST
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:MI
Practice Address - Zip Code:48184-1775
Practice Address - Country:US
Practice Address - Phone:313-657-7762
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-07
Last Update Date:2021-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide