Provider Demographics
NPI:1609906486
Name:ANDERSON, TRACY ANN (LVN)
Entity type:Individual
Prefix:MS
First Name:TRACY
Middle Name:ANN
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:LVN
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 901762
Mailing Address - Street 2:
Mailing Address - City:PALMDALE
Mailing Address - State:CA
Mailing Address - Zip Code:93590-1762
Mailing Address - Country:US
Mailing Address - Phone:661-209-2698
Mailing Address - Fax:
Practice Address - Street 1:12450 VAN NUYS BLVD
Practice Address - Street 2:
Practice Address - City:PACOIMA
Practice Address - State:CA
Practice Address - Zip Code:91331-1391
Practice Address - Country:US
Practice Address - Phone:818-896-1161
Practice Address - Fax:818-896-1462
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7420Medicaid
CA7068Medicaid