Basic Information
Provider Information | |||||||||
NPI: | 1841369899 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PRAYNER | ||||||||
FirstName: | TRACI | ||||||||
MiddleName: | LYNN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | CRNA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 9040 JACKSON AVE | ||||||||
Address2: |   | ||||||||
City: | TACOMA | ||||||||
State: | WA | ||||||||
PostalCode: | 984310001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2539683744 | ||||||||
FaxNumber: | 2539683278 | ||||||||
Practice Location | |||||||||
Address1: | 9040 JACKSON AVE | ||||||||
Address2: |   | ||||||||
City: | TACOMA | ||||||||
State: | WA | ||||||||
PostalCode: | 984310001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2539683744 | ||||||||
FaxNumber: | 2539683278 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/06/2006 | ||||||||
LastUpdateDate: | 11/24/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/24/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 55608 | KS | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   | 367500000X | AP60134098 | WA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   | 163WC0200X | 0001171560 | VA | N |   | Nursing Service Providers | Registered Nurse | Critical Care Medicine | 367500000X | TEMPORARY | CA | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   |
ID Information
ID | Type | State | Issuer | Description | 0292062 | 01 | WA | LABOR AND INDUSTRY | OTHER | 1841369899 | 05 | WA |   | MEDICAID | 200440240A | 05 | KS |   | MEDICAID | 145946 | 01 | KS | BCBS | OTHER |