Healthcare Provider Details

I. General information

NPI: 1972573855
Provider Name (Legal Business Name): TRACEY MENDELSON N.N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2006
Last Update Date: 02/10/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6215 HUMPHREYS BLVD STE 310
MEMPHIS TN
38120-2367
US

IV. Provider business mailing address

6215 HUMPHREYS BLVD STE 310
MEMPHIS TN
38120-2367
US

V. Phone/Fax

Practice location:
  • Phone: 901-747-0291
  • Fax: 901-747-0299
Mailing address:
  • Phone: 901-747-0291
  • Fax: 901-747-0299

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LN0000X
TaxonomyNeonatal Nurse Practitioner
License Number81-0027
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: