Healthcare Provider Details

I. General information

NPI: 1134342066
Provider Name (Legal Business Name): JOHN TRACY RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2707 BROWNS LN
JONESBORO AR
72401-7213
US

IV. Provider business mailing address

2707 BROWNS LN
JONESBORO AR
72401-7213
US

V. Phone/Fax

Practice location:
  • Phone: 870-972-4939
  • Fax: 870-972-4911
Mailing address:
  • Phone: 870-972-4939
  • Fax: 870-972-4911

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License NumberR65106
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: