Provider Demographics
NPI:1851550115
Name:VANDER REYDEN, TRACY LYNN (FNP)
Entity Type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:LYNN
Last Name:VANDER REYDEN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:LYNN
Other - Last Name:LYLES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:2006 S MAIN ST STE A
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:IN
Mailing Address - Zip Code:46526-5232
Mailing Address - Country:US
Mailing Address - Phone:574-535-9100
Mailing Address - Fax:
Practice Address - Street 1:2006 S MAIN ST STE A
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46526-5232
Practice Address - Country:US
Practice Address - Phone:574-535-9100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-03
Last Update Date:2020-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704267843363LF0000X
IN71002404A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner