Provider Demographics
NPI:1932514254
Name:STUDMIRE, TRACENA ANNETTE (HOME HEALTH)
Entity Type:Individual
Prefix:MRS
First Name:TRACENA
Middle Name:ANNETTE
Last Name:STUDMIRE
Suffix:
Gender:F
Credentials:HOME HEALTH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12513 WISCONSIN WOODS LN
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32824-9022
Mailing Address - Country:US
Mailing Address - Phone:321-682-6819
Mailing Address - Fax:
Practice Address - Street 1:351 DELANCEY DR
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:FL
Practice Address - Zip Code:33837-7644
Practice Address - Country:US
Practice Address - Phone:321-682-6819
Practice Address - Fax:407-870-9605
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-25
Last Update Date:2015-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL005538400103TA0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL005538400Medicaid