Healthcare Provider Details

I. General information

NPI: 1417388612
Provider Name (Legal Business Name): TRACY ROMANELLO DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2013
Last Update Date: 10/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14875 NW 77TH AVE STE 201
MIAMI LAKES FL
33014-2568
US

IV. Provider business mailing address

600 S LAKE DASHA DR
PLANTATION FL
33324-3132
US

V. Phone/Fax

Practice location:
  • Phone: 305-351-7139
  • Fax: 305-824-0665
Mailing address:
  • Phone: 954-383-7166
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QH0002X
TaxonomyHospice and Palliative Medicine (Family Medicine) Physician
License NumberOS12424
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS12424
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: