Provider Demographics
NPI:1356926166
Name:STALLWORTH, TRACY M
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:M
Last Name:STALLWORTH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4302 HELIOTROPE LOOP
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34746-3477
Mailing Address - Country:US
Mailing Address - Phone:407-883-1243
Mailing Address - Fax:
Practice Address - Street 1:4302 HELIOTROPE LOOP
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34746-3477
Practice Address - Country:US
Practice Address - Phone:407-883-1243
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-12
Last Update Date:2021-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor