Provider Demographics
NPI:1902085194
Name:MCDONOUGH, TRACEY LYNN (LPN)
Entity Type:Individual
Prefix:MRS
First Name:TRACEY
Middle Name:LYNN
Last Name:MCDONOUGH
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 1:221 HOSPITAL DR NE
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32548-5066
Mailing Address - Country:US
Mailing Address - Phone:850-833-9240
Mailing Address - Fax:
Practice Address - Street 1:150 RICHBOURG AVE
Practice Address - Street 2:
Practice Address - City:SHALIMAR
Practice Address - State:FL
Practice Address - Zip Code:32579-1221
Practice Address - Country:US
Practice Address - Phone:850-833-4301
Practice Address - Fax:850-833-4395
Is Sole Proprietor?:No
Enumeration Date:2007-10-24
Last Update Date:2007-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPN5156934164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse