Healthcare Provider Details

I. General information

NPI: 1982978771
Provider Name (Legal Business Name): TRACI EVANS NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2012
Last Update Date: 12/17/2024
Certification Date: 12/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4540 W RAILROAD ST
GULFPORT MS
39501-2480
US

IV. Provider business mailing address

PO BOX 1810
GULFPORT MS
39502-1810
US

V. Phone/Fax

Practice location:
  • Phone: 228-867-6062
  • Fax: 228-867-2598
Mailing address:
  • Phone: 228-867-6062
  • Fax: 228-867-2598

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberR877630
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: