Provider Demographics
NPI:1760808810
Name:WELLER, TRACY LYNN (PTA)
Entity Type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:LYNN
Last Name:WELLER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1331 5TH AVE.
Mailing Address - Street 2:
Mailing Address - City:DEWITT
Mailing Address - State:IA
Mailing Address - Zip Code:52742
Mailing Address - Country:US
Mailing Address - Phone:563-340-9161
Mailing Address - Fax:
Practice Address - Street 1:1331 5TH AVE.
Practice Address - Street 2:
Practice Address - City:DEWITT
Practice Address - State:IA
Practice Address - Zip Code:52742
Practice Address - Country:US
Practice Address - Phone:563-340-9161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-13
Last Update Date:2014-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00333225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA00333OtherIA STATE LICENSE