Provider Demographics
NPI:1922799659
Name:BERG, TRACY LYNN (APRN)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:LYNN
Last Name:BERG
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:LYNN
Other - Last Name:IDOCKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:19411 SWEET GRASS WAY
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33558-5016
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7171 N DALE MABRY HWY
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614-2665
Practice Address - Country:US
Practice Address - Phone:813-558-4918
Practice Address - Fax:813-558-4989
Is Sole Proprietor?:No
Enumeration Date:2023-05-15
Last Update Date:2023-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11025897363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner