Provider Demographics
NPI:1033605514
Name:WYRICK, TRACY L (FNP-BC)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:L
Last Name:WYRICK
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:418 CRANE ST
Mailing Address - Street 2:
Mailing Address - City:PARK HILLS
Mailing Address - State:MO
Mailing Address - Zip Code:63601-1906
Mailing Address - Country:US
Mailing Address - Phone:573-259-1053
Mailing Address - Fax:
Practice Address - Street 1:418 CRANE ST
Practice Address - Street 2:
Practice Address - City:PARK HILLS
Practice Address - State:MO
Practice Address - Zip Code:63601-1906
Practice Address - Country:US
Practice Address - Phone:573-259-1053
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-07
Last Update Date:2018-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018024153363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily