Provider Demographics
NPI:1073025409
Name:NELSON, TRACY ZANETA (OWNER)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:ZANETA
Last Name:NELSON
Suffix:
Gender:F
Credentials:OWNER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2135 DAVIS ST
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33916-4413
Mailing Address - Country:US
Mailing Address - Phone:239-355-0686
Mailing Address - Fax:
Practice Address - Street 1:5624 7TH AVE
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-2927
Practice Address - Country:US
Practice Address - Phone:561-939-9510
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-25
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL234643253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care