Provider Demographics
NPI:1235762196
Name:WHITEHURST, TRACY
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:WHITEHURST
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 1:7880 SONOMA SPRINGS CIR APT 105
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33463-7935
Mailing Address - Country:US
Mailing Address - Phone:561-644-1299
Mailing Address - Fax:
Practice Address - Street 1:7880 SONOMA SPRINGS CIR APT 105
Practice Address - Street 2:
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33463-7935
Practice Address - Country:US
Practice Address - Phone:561-644-1299
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-19
Last Update Date:2020-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPN5197616164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse