Provider Demographics
NPI:1013031418
Name:HENNEMANN, TRACY A (PT)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:A
Last Name:HENNEMANN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:A
Other - Last Name:JAILLETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:116 E BLOOMINGDALE AVE
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-8101
Mailing Address - Country:US
Mailing Address - Phone:891-365-5334
Mailing Address - Fax:813-653-0894
Practice Address - Street 1:116 E BLOOMINGDALE AVE
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-8101
Practice Address - Country:US
Practice Address - Phone:891-365-5334
Practice Address - Fax:813-653-0894
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT23000225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPT23000OtherSTATE LICENSE NUMBER