Provider Demographics
NPI:1629537113
Name:WESLEY, TRACI LYNN
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:LYNN
Last Name:WESLEY
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 1:212 W WINTERGREEN RD APT 1039
Mailing Address - Street 2:
Mailing Address - City:DESOTO
Mailing Address - State:TX
Mailing Address - Zip Code:75115-2347
Mailing Address - Country:US
Mailing Address - Phone:214-677-8189
Mailing Address - Fax:972-217-3425
Practice Address - Street 1:235 W PLEASANT RUN RD
Practice Address - Street 2:
Practice Address - City:CEDAR HILL
Practice Address - State:TX
Practice Address - Zip Code:75104-5436
Practice Address - Country:US
Practice Address - Phone:214-677-8189
Practice Address - Fax:972-217-3425
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-14
Last Update Date:2019-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health