Provider Demographics
NPI:1578810396
Name:HERRMANN, TRACY LYNN (PT)
Entity Type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:LYNN
Last Name:HERRMANN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1922 DREXEL HILL CT
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63131-3647
Mailing Address - Country:US
Mailing Address - Phone:314-650-4958
Mailing Address - Fax:
Practice Address - Street 1:680 S 4TH ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-2407
Practice Address - Country:US
Practice Address - Phone:314-822-6285
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-10
Last Update Date:2012-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR1109310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility