Individual
MRS. AUTUMN SUSAN TRACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
LPN
Contact information
Practice address
710 JACKSON HILL RD, JACKSON, OH 45640-9301
(740) 286-0212
Mailing address
710 JACKSON HILL RD, JACKSON, OH 45640-9301
(740) 286-0212
Taxonomy
Speciality
Code
Description
License number
State
164W00000X
Licensed Practical Nurse
Primary
PN050719
OH
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
2578545
—
OH
Enumeration date
01/31/2007
Last updated
07/09/2007
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