Healthcare Provider Details

I. General information

NPI: 1811536816
Provider Name (Legal Business Name): DR. TRACEY LUANNA WYLIE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/23/2019
Last Update Date: 12/23/2019
Certification Date: 12/23/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1989 PARK ST
SHELDON IA
51201-8535
US

IV. Provider business mailing address

633 6TH ST
ASHTON IA
51232-7087
US

V. Phone/Fax

Practice location:
  • Phone: 712-324-0020
  • Fax: 712-324-9802
Mailing address:
  • Phone: 319-541-3620
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number22028
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: