Provider Demographics
NPI:1104213719
Name:SANDERBECK, TRACEY (ARNP)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:
Last Name:SANDERBECK
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8253 113TH ST
Mailing Address - Street 2:STE 100
Mailing Address - City:SEMINOLE
Mailing Address - State:FL
Mailing Address - Zip Code:33772-4128
Mailing Address - Country:US
Mailing Address - Phone:813-636-8811
Mailing Address - Fax:813-636-8855
Practice Address - Street 1:8253 113TH ST
Practice Address - Street 2:
Practice Address - City:SEMINOLE
Practice Address - State:FL
Practice Address - Zip Code:33772-4128
Practice Address - Country:US
Practice Address - Phone:727-295-5050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-21
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QM0801X
FLARNP9168905363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL020971300Medicaid
FL020971300Medicaid