Provider Demographics
NPI:1659836484
Name:WENTZ, TRACI LYNN (PMHNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:TRACI
Middle Name:LYNN
Last Name:WENTZ
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1555 NE RICE RD
Mailing Address - Street 2:
Mailing Address - City:LEES SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:64086-5849
Mailing Address - Country:US
Mailing Address - Phone:816-988-2739
Mailing Address - Fax:
Practice Address - Street 1:7001 BLUE RIDGE BLVD
Practice Address - Street 2:
Practice Address - City:RAYTOWN
Practice Address - State:MO
Practice Address - Zip Code:64133-5629
Practice Address - Country:US
Practice Address - Phone:816-988-2739
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-06
Last Update Date:2022-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019003451363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health