Provider Demographics
NPI:1164062279
Name:NIERTH, TRACY (RN)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:NIERTH
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:EDGE
Other - Last Name:WEISBROD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:201 SIMONE WAY
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-7750
Mailing Address - Country:US
Mailing Address - Phone:904-829-1770
Mailing Address - Fax:
Practice Address - Street 1:201 SIMONE WAY
Practice Address - Street 2:
Practice Address - City:SAINT AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-7750
Practice Address - Country:US
Practice Address - Phone:904-829-1770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-07
Last Update Date:2020-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN2166362163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse