Provider Demographics
NPI:1659825123
Name:WYNGAARD, TRACY L (APNP)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:L
Last Name:WYNGAARD
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 601843
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-1843
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:50 MILLER ST STE C
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27104-4206
Practice Address - Country:US
Practice Address - Phone:336-310-5535
Practice Address - Fax:336-310-1183
Is Sole Proprietor?:No
Enumeration Date:2016-08-12
Last Update Date:2021-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7132363L00000X
NC5011861363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner