Healthcare Provider Details

I. General information

NPI: 1841734688
Provider Name (Legal Business Name): TRACY BASHAM FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/13/2016
Last Update Date: 04/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 E VERMILLION ST
ATHENS WV
24712-8005
US

IV. Provider business mailing address

118 12TH STREET EXT
PRINCETON WV
24740-2352
US

V. Phone/Fax

Practice location:
  • Phone: 304-384-7325
  • Fax:
Mailing address:
  • Phone: 304-431-5168
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number49397NP
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: