Provider Demographics
NPI:1013489202
Name:WATFORD, TRACY N
Entity Type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:N
Last Name:WATFORD
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 1:2720 ANCHOR RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURG
Mailing Address - State:FL
Mailing Address - Zip Code:32068-5600
Mailing Address - Country:US
Mailing Address - Phone:904-704-6012
Mailing Address - Fax:
Practice Address - Street 1:2720 ANCHOR RD
Practice Address - Street 2:
Practice Address - City:MIDDLEBURG
Practice Address - State:FL
Practice Address - Zip Code:32068-5600
Practice Address - Country:US
Practice Address - Phone:904-704-6012
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-28
Last Update Date:2018-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0043191003747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004319100Medicaid