Provider Demographics
NPI:1144057761
Name:KHATIERA, TRACEY MABEL
Entity type:Individual
Prefix:
First Name:TRACEY
Middle Name:MABEL
Last Name:KHATIERA
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 1:1460 SW PANORAMA DR
Mailing Address - Street 2:
Mailing Address - City:PULLMAN
Mailing Address - State:WA
Mailing Address - Zip Code:99163-7301
Mailing Address - Country:US
Mailing Address - Phone:413-262-4360
Mailing Address - Fax:
Practice Address - Street 1:1460 SW PANORAMA DR
Practice Address - Street 2:
Practice Address - City:PULLMAN
Practice Address - State:WA
Practice Address - Zip Code:99163-7301
Practice Address - Country:US
Practice Address - Phone:413-262-4360
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-17
Last Update Date:2024-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAHM61106291374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide