=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194488148
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TRACIE LAINE CARNEY CNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/18/2021
-----------------------------------------------------
Last Update Date | 10/18/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4801 JACKSON ST # B
-----------------------------------------------------
City | ALEXANDRIA
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71303-2508
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-266-8656
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1192 HIGHWAY 115
-----------------------------------------------------
City | DEVILLE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71328-9290
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-419-8310
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 219539
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------