Healthcare Provider Details

I. General information

NPI: 1063458586
Provider Name (Legal Business Name): TRACY C WADE ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2006
Last Update Date: 05/07/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

242 BROCKFORD RD
HEFLIN AL
36264-1608
US

IV. Provider business mailing address

1411 PIEDMONT CUTOFF
GADSDEN AL
35903-2708
US

V. Phone/Fax

Practice location:
  • Phone: 256-463-2021
  • Fax: 256-463-2024
Mailing address:
  • Phone: 256-492-0131
  • Fax: 256-494-6000

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number1-074382NP
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: