Provider Demographics
NPI:1619708260
Name:SENIOR, TRACEY JUDITH LATIA (STNA)
Entity type:Individual
Prefix:
First Name:TRACEY
Middle Name:JUDITH LATIA
Last Name:SENIOR
Suffix:
Gender:F
Credentials:STNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4104 ORCHARD DALE DR NW APT N
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44709-2095
Mailing Address - Country:US
Mailing Address - Phone:716-510-4216
Mailing Address - Fax:
Practice Address - Street 1:4104 ORCHARD DALE DR NW APT N
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44709-2095
Practice Address - Country:US
Practice Address - Phone:716-510-4216
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-13
Last Update Date:2024-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH602837170524376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide