MEDICARE: MRS. TRACY MARIE WIRTH F.N.P.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	4704195788	MI

General Provider Information

NPI Number	:	1760795983
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. TRACY MARIE WIRTH F.N.P.

Provider Business Mailing Address
First Line	:	1035 CHARLEVOIX DR
Second Line	:	STE 100
City	:	GRAND LEDGE
State	:	MI
Zip	:	48837-2223
Country	:	US
Telephone Number	:	989-224-3000
Fax Number	:	989-224-1424

Provider Business Practice Location Address
First Line	:	1055 S US HIGHWAY 27
Second Line	:
City	:	SAINT JOHNS
State	:	MI
Zip	:	48879-2437
Country	:	US
Telephone Number	:	989-224-3000
Fax Number	:	989-224-1424

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/16/2010
Last Update Date	:	09/07/2017

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