1093386740 NPI number — TRACI D ANDERSON APRN

Table of content: TRACI D ANDERSON APRN (NPI 1093386740)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093386740 NPI number — TRACI D ANDERSON APRN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ANDERSON
Provider First Name:
TRACI
Provider Middle Name:
D
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
APRN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093386740
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/05/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
310 N L ROGERS WELLS BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GLASGOW
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
42141-1300
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
270-651-1111
Provider Business Mailing Address Fax Number:
270-651-1892

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
310 N L ROGERS WELLS BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GLASGOW
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42141-1300
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-659-3398
Provider Business Practice Location Address Fax Number:
270-651-1892
Provider Enumeration Date:
07/05/2021

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  3016283 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)