Provider Demographics
NPI:1750318242
Name:FENN, TRACY A (PA-C)
Entity Type:Individual
Prefix:MS
First Name:TRACY
Middle Name:A
Last Name:FENN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 GRETA LN
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NC
Mailing Address - Zip Code:27537-3475
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:LUMAR PLAZA, 1847 PSL BLVD
Practice Address - Street 2:WELLMED MEDICAL MANAGMENT OF FLORIDA, INC.
Practice Address - City:PORT ST. LUCIE
Practice Address - State:FL
Practice Address - Zip Code:94952
Practice Address - Country:US
Practice Address - Phone:772-579-2303
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2008-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical