MEDICARE: TRACIE LEDORA MITCHEM-GREEN F.N.P

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP2300X	Primary Care Nurse Practitioner	2981	SC
2	363LF0000X	Family Nurse Practitioner	9304575	FL
3	363L00000X	Nurse Practitioner	2981	SC
4	363LP2300X	Primary Care Nurse Practitioner	ARNP9304575	FL
5	363LP2300X	Primary Care Nurse Practitioner	342892	NY

General Provider Information

NPI Number	:	1942321575
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TRACIE LEDORA MITCHEM-GREEN F.N.P

Provider Business Mailing Address
First Line	:	295 NW COMMONS LOOP # 115-105
Second Line	:
City	:	LAKE CITY
State	:	FL
Zip	:	32055-7721
Country	:	US
Telephone Number	:	803-381-7690
Fax Number	:

Provider Business Practice Location Address
First Line	:	295 NW COMMONS LOOP # 115-105
Second Line	:
City	:	LAKE CITY
State	:	FL
Zip	:	32055-7721
Country	:	US
Telephone Number	:	803-381-7690
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/02/2007
Last Update Date	:	05/10/2018

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