Provider Demographics
NPI:1861141624
Name:SCOTT, TRACI DANIELLE (LPN)
Entity type:Individual
Prefix:
First Name:TRACI
Middle Name:DANIELLE
Last Name:SCOTT
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:PO BOX 14037
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32238-1037
Mailing Address - Country:US
Mailing Address - Phone:904-382-6261
Mailing Address - Fax:
Practice Address - Street 1:2211 BURPEE DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32210-3728
Practice Address - Country:US
Practice Address - Phone:904-382-6261
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-21
Last Update Date:2022-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLS300804885150OtherDRIVER LICENSE