Healthcare Provider Details

I. General information

NPI: 1356667059
Provider Name (Legal Business Name): TRACY D MANDRYK NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2010
Last Update Date: 09/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 OUTLET CENTER DR SUITE 230
OXNARD CA
93036-0663
US

IV. Provider business mailing address

1011 WATERBURY LN
VENTURA CA
93001-3841
US

V. Phone/Fax

Practice location:
  • Phone: 805-983-6233
  • Fax:
Mailing address:
  • Phone: 805-766-2750
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number388425
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number388425
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: