Healthcare Provider Details

I. General information

NPI: 1689256075
Provider Name (Legal Business Name): TRACY DENISE WILSON FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2021
Last Update Date: 04/19/2022
Certification Date: 04/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1911 MISSION 66 STE B
VICKSBURG MS
39180-3762
US

IV. Provider business mailing address

4055 N PARK LOOP
MEMPHIS TN
38152-4220
US

V. Phone/Fax

Practice location:
  • Phone: 601-665-4162
  • Fax: 855-830-3484
Mailing address:
  • Phone: 901-678-2003
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number904985
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: