Healthcare Provider Details

I. General information

NPI: 1003239294
Provider Name (Legal Business Name): TRACY LEIGH LADNER C.F.N.P
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2014
Last Update Date: 09/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15200 COMMUNITY RD
GULFPORT MS
39503-3085
US

IV. Provider business mailing address

PO BOX 1729
HATTIESBURG MS
39403-1729
US

V. Phone/Fax

Practice location:
  • Phone: 228-575-7000
  • Fax:
Mailing address:
  • Phone: 601-545-8700
  • Fax: 601-450-2493

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR850568
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: