Healthcare Provider Details

I. General information

NPI: 1487613774
Provider Name (Legal Business Name): TRACEY MULLINS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2006
Last Update Date: 07/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 RIVER RD
GREENWOOD MS
38930-4030
US

IV. Provider business mailing address

PO BOX 369
VAIDEN MS
39176-0369
US

V. Phone/Fax

Practice location:
  • Phone: 662-459-7000
  • Fax: 662-459-1147
Mailing address:
  • Phone: 662-464-5470
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberR681857
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: