Provider Demographics
NPI:1063653913
Name:VANESS, TRACY ANN
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:ANN
Last Name:VANESS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8121 25TH AVE N
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33710-3629
Mailing Address - Country:US
Mailing Address - Phone:727-687-1801
Mailing Address - Fax:
Practice Address - Street 1:8121 25TH AVE N
Practice Address - Street 2:
Practice Address - City:SAINT PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33710-3629
Practice Address - Country:US
Practice Address - Phone:727-687-1801
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-23
Last Update Date:2009-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL685226279Medicaid