Healthcare Provider Details

I. General information

NPI: 1053973321
Provider Name (Legal Business Name): TRACY ELAINE BUSH CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2019
Last Update Date: 11/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1131 LEIGHTON AVE
ANNISTON AL
36207-4610
US

IV. Provider business mailing address

6001 ENCLAVE PL
TRUSSVILLE AL
35173-3833
US

V. Phone/Fax

Practice location:
  • Phone: 256-237-0025
  • Fax:
Mailing address:
  • Phone: 205-960-0291
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number1-091713
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number1-091713
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: