Provider Demographics
NPI:1639521057
Name:WYTTENBACH, TRACEY (LPN)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:
Last Name:WYTTENBACH
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5640 SEMINOLE BLVD LOT 349
Mailing Address - Street 2:
Mailing Address - City:SEMINOLE
Mailing Address - State:FL
Mailing Address - Zip Code:33772-7326
Mailing Address - Country:US
Mailing Address - Phone:407-276-7519
Mailing Address - Fax:
Practice Address - Street 1:5640 SEMINOLE BLVD LOT 349
Practice Address - Street 2:
Practice Address - City:SEMINOLE
Practice Address - State:FL
Practice Address - Zip Code:33772-7326
Practice Address - Country:US
Practice Address - Phone:407-276-7519
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-09
Last Update Date:2016-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPN5223302164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse