Healthcare Provider Details

I. General information

NPI: 1912957135
Provider Name (Legal Business Name): TRACY HENNESSEY CFNP
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

404 MAIN ST
NEW AUGUSTA MS
39462-0000
US

IV. Provider business mailing address

PO BOX 1729
HATTIESBURG MS
39403-1729
US

V. Phone/Fax

Practice location:
  • Phone: 601-964-8391
  • Fax: 601-964-8393
Mailing address:
  • Phone: 601-545-8700
  • Fax: 601-582-5461

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR854915
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: