Basic Information
| Provider Information | |||||||||
| NPI: | 1386946556 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SPAFFORD | ||||||||
| FirstName: | TRACEY | ||||||||
| MiddleName: | DYAN | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | R.N | ||||||||
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| Mailing Information | |||||||||
| Address1: | 44 NICOLE DR | ||||||||
| Address2: | |||||||||
| City: | INDEPENDENCE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410517317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593590191 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1 MEDICAL VILLAGE DR | ||||||||
| Address2: | |||||||||
| City: | EDGEWOOD | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410173403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593417246 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/22/2010 | ||||||||
| LastUpdateDate: | 04/18/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 1118099 | KY | N | Nursing Service Providers | Registered Nurse | 163W00000X | RN 322985 | OH | N | Nursing Service Providers | Registered Nurse | 367500000X | 085937 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 611077369 1295716850 | 01 | HEALTHNET | OTHER | 201008860 | 05 | IN | MEDICAID | 3125620 | 05 | OH | MEDICAID | 000000702876 | 01 | ANTHEM | OTHER | 7100148650 | 05 | KY | MEDICAID |