Provider Demographics
NPI:1538833405
Name:LEE, TRACY SUE
Entity type:Individual
Prefix:MS
First Name:TRACY
Middle Name:SUE
Last Name:LEE
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 1:324 STINEBAUGH DR
Mailing Address - Street 2:
Mailing Address - City:WAPAKONETA
Mailing Address - State:OH
Mailing Address - Zip Code:45895-1242
Mailing Address - Country:US
Mailing Address - Phone:419-296-5878
Mailing Address - Fax:
Practice Address - Street 1:324 STINEBAUGH DR
Practice Address - Street 2:
Practice Address - City:WAPAKONETA
Practice Address - State:OH
Practice Address - Zip Code:45895-1242
Practice Address - Country:US
Practice Address - Phone:419-296-5878
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-04
Last Update Date:2021-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0601021376J00000X
OH0200040376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker