Healthcare Provider Details

I. General information

NPI: 1033394804
Provider Name (Legal Business Name): TRACY RENEE PILGRIM APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/29/2007
Last Update Date: 03/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 NATHAN ST
MARKED TREE AR
72365
US

IV. Provider business mailing address

49 HIGHWAY 62 412
ASH FLAT AR
72513-9594
US

V. Phone/Fax

Practice location:
  • Phone: 870-358-2036
  • Fax: 870-358-4116
Mailing address:
  • Phone: 870-358-2036
  • Fax: 870-358-4116

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberA01248
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: