Provider Demographics
NPI:1497439178
Name:WECKER, TRACIE K
Entity Type:Individual
Prefix:
First Name:TRACIE
Middle Name:K
Last Name:WECKER
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 1:523 HERITAGE PARK BLVD STE 4
Mailing Address - Street 2:
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84041-5611
Mailing Address - Country:US
Mailing Address - Phone:801-525-9998
Mailing Address - Fax:
Practice Address - Street 1:523 HERITAGE PARK BLVD STE 4
Practice Address - Street 2:
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041-5611
Practice Address - Country:US
Practice Address - Phone:801-525-9998
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-13
Last Update Date:2023-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT211810-3102163WA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)