Provider Demographics
NPI:1811536816
Name:WYLIE, TRACEY LUANNA
Entity Type:Individual
Prefix:DR
First Name:TRACEY
Middle Name:LUANNA
Last Name:WYLIE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:633 6TH ST
Mailing Address - Street 2:
Mailing Address - City:ASHTON
Mailing Address - State:IA
Mailing Address - Zip Code:51232-7087
Mailing Address - Country:US
Mailing Address - Phone:319-541-3620
Mailing Address - Fax:
Practice Address - Street 1:1989 PARK ST
Practice Address - Street 2:
Practice Address - City:SHELDON
Practice Address - State:IA
Practice Address - Zip Code:51201-8535
Practice Address - Country:US
Practice Address - Phone:712-324-0020
Practice Address - Fax:712-324-9802
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-23
Last Update Date:2019-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA22028183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist