Healthcare Provider Details

I. General information

NPI: 1144341330
Provider Name (Legal Business Name): TRACEY L MENDELSOHN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

495 TAYLOR RD
MONTGOMERY AL
36117-3513
US

IV. Provider business mailing address

495 TAYLOR RD
MONTGOMERY AL
36117-3513
US

V. Phone/Fax

Practice location:
  • Phone: 334-279-9333
  • Fax: 334-279-9057
Mailing address:
  • Phone: 334-279-9333
  • Fax: 334-279-9057

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number1047856
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: