Provider Demographics
NPI:1578261038
Name:DODGEN, TRACY JANE I
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:JANE
Last Name:DODGEN
Suffix:I
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 1:15131 FICUS ST
Mailing Address - Street 2:
Mailing Address - City:LAKE ELSINORE
Mailing Address - State:CA
Mailing Address - Zip Code:92530-7338
Mailing Address - Country:US
Mailing Address - Phone:949-395-8584
Mailing Address - Fax:
Practice Address - Street 1:14016 A ST S
Practice Address - Street 2:
Practice Address - City:PARKLAND
Practice Address - State:WA
Practice Address - Zip Code:98444-4662
Practice Address - Country:US
Practice Address - Phone:949-395-8584
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-22
Last Update Date:2024-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61404087163WP0808X
CA95221355163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health