Healthcare Provider Details

I. General information

NPI: 1780917443
Provider Name (Legal Business Name): TRACEY L MAYS F.N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2009
Last Update Date: 03/01/2023
Certification Date: 03/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3964 GOODMAN RD E STE 128-129
SOUTHAVEN MS
38672-8761
US

IV. Provider business mailing address

3964 GOODMAN RD E STE 128-129
SOUTHAVEN MS
38672-8761
US

V. Phone/Fax

Practice location:
  • Phone: 662-655-0456
  • Fax: 662-655-0457
Mailing address:
  • Phone: 662-655-0456
  • Fax: 662-655-0457

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR868008
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: