Provider Demographics
NPI:1649502824
Name:LANDRUM, TRACEY
Entity type:Individual
Prefix:
First Name:TRACEY
Middle Name:
Last Name:LANDRUM
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 1:37 OCEAN BREEZE CIR
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32176-2821
Mailing Address - Country:US
Mailing Address - Phone:386-290-7553
Mailing Address - Fax:
Practice Address - Street 1:300 INTERNATIONAL PKWY
Practice Address - Street 2:
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-5035
Practice Address - Country:US
Practice Address - Phone:407-732-5848
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-12
Last Update Date:2010-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA10905171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor