Healthcare Provider Details

I. General information

NPI: 1639521057
Provider Name (Legal Business Name): TRACEY WYTTENBACH LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/09/2016
Last Update Date: 07/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5640 SEMINOLE BLVD LOT 349
SEMINOLE FL
33772-7326
US

IV. Provider business mailing address

5640 SEMINOLE BLVD LOT 349
SEMINOLE FL
33772-7326
US

V. Phone/Fax

Practice location:
  • Phone: 407-276-7519
  • Fax:
Mailing address:
  • Phone: 407-276-7519
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberPN5223302
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: