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General NPI Number Information
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NPI Number | 1336868371
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Entity Type | Individual
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Provider Name | TRACEY GRAYER NURSE PRACTITIONER
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Gender | Female
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Dates
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Enumeration Date | 08/23/2022
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Last Update Date | 08/23/2022
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Provider Practice Location Address
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Address Line | 3502 W NORTHSIDE DR
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City | JACKSON
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State | MS
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Zip | 39213-4454
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Country | US
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Telephone | 601-362-5321
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Fax | 601-364-5159
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Provider Business Mailing Address
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Address Line | PO BOX 545
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City | MADISON
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State | MS
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Zip | 39130-0545
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Country | US
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Telephone | 770-546-6270
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LG0600X
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Taxonomy Name | Gerontology Nurse Practitioner
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License Number | 905260
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License Number State | MS
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