1417022138 NPI number — MISS TRACY LYNN WANNEMACHER MS CCC SLPL

Table of content: MISS TRACY LYNN WANNEMACHER MS CCC SLPL (NPI 1417022138)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417022138 NPI number — MISS TRACY LYNN WANNEMACHER MS CCC SLPL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WANNEMACHER
Provider First Name:
TRACY
Provider Middle Name:
LYNN
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
MS CCC SLPL
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1417022138
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1254 PULLMAN RD
Provider Second Line Business Mailing Address:
APT 304
Provider Business Mailing Address City Name:
ROMEOVILLE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60446
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-260-6596
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1001 EAST CHICAGO AVENUE
Provider Second Line Business Practice Location Address:
SUITE 151
Provider Business Practice Location Address City Name:
NAPERVILLE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60540
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
630-305-4196
Provider Business Practice Location Address Fax Number:
630-305-4785
Provider Enumeration Date:
11/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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