Provider Demographics
NPI:1992098255
Name:BRENNER, TRACY LEE (LVN)
Entity type:Individual
Prefix:MISS
First Name:TRACY
Middle Name:LEE
Last Name:BRENNER
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3002 ARMSTRONG ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92111-5702
Mailing Address - Country:US
Mailing Address - Phone:858-277-9550
Mailing Address - Fax:858-874-5266
Practice Address - Street 1:3002 ARMSTRONG ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92111-5702
Practice Address - Country:US
Practice Address - Phone:858-277-9550
Practice Address - Fax:858-874-5266
Is Sole Proprietor?:No
Enumeration Date:2011-05-19
Last Update Date:2011-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN145383164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse