Provider Demographics
NPI:1598873663
Name:VANDERSCHAAF, TRACY LYNEE (R, M, MR)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:LYNEE
Last Name:VANDERSCHAAF
Suffix:
Gender:F
Credentials:R, M, MR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50128 130TH AVE
Mailing Address - Street 2:
Mailing Address - City:LAURENS
Mailing Address - State:IA
Mailing Address - Zip Code:50554-8522
Mailing Address - Country:US
Mailing Address - Phone:850-832-4970
Mailing Address - Fax:
Practice Address - Street 1:511 E 23RD ST
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-5307
Practice Address - Country:US
Practice Address - Phone:850-747-1140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2008-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL050748247100000X
2408762471M1202X, 2471M2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2471M1202XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistMagnetic Resonance Imaging
No247100000XTechnologists, Technicians & Other Technical Service ProvidersRadiologic Technologist
No2471M2300XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistMammography