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General NPI Number Information
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NPI Number | 1568082006
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Entity Type | Individual
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Provider Name | TRACIE LANE GILLILAND MSN, APRN, FNP-BC
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Gender | Female
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Dates
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Enumeration Date | 04/24/2020
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Last Update Date | 04/24/2020
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Provider Practice Location Address
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Address Line | 360 MC 7097
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City | FLIPPIN
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State | AR
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Zip | 72634-8419
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Country | US
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Telephone | 870-404-2347
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Fax |
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Provider Business Mailing Address
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Address Line | 360 MC 7097
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City | FLIPPIN
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State | AR
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Zip | 72634-8419
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Country | US
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Telephone | 870-404-2347
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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 | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 124431
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License Number State | AR
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