Healthcare Provider Details

I. General information

NPI: 1053635391
Provider Name (Legal Business Name): TRACI CAMERON NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2010
Last Update Date: 04/27/2024
Certification Date: 04/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 NACOGDOCHES ST SUITE 280
JACKSONVILLE TX
75766-2462
US

IV. Provider business mailing address

901 TURTLE CREEK DR
TYLER TX
75701-1947
US

V. Phone/Fax

Practice location:
  • Phone: 903-541-5455
  • Fax: 903-541-5456
Mailing address:
  • Phone: 903-596-3588
  • Fax: 903-594-2038

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number712611
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number118197
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: