Healthcare Provider Details

I. General information

NPI: 1750681920
Provider Name (Legal Business Name): TRACY THOMAS GUM APRN, FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/22/2010
Last Update Date: 08/09/2021
Certification Date: 07/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 FUSELIER RD
ARNAUDVILLE LA
70512-6134
US

IV. Provider business mailing address

PO BOX 618
ARNAUDVILLE LA
70512-0618
US

V. Phone/Fax

Practice location:
  • Phone: 225-936-8990
  • Fax:
Mailing address:
  • Phone: 225-936-8990
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP06308
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN096007-AP06308
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: