MEDICARE: TRACY HENNESSEY CFNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	R854915	MS

General Provider Information

NPI Number	:	1912957135
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TRACY HENNESSEY CFNP

Provider Business Mailing Address
First Line	:	PO BOX 1729
Second Line	:
City	:	HATTIESBURG
State	:	MS
Zip	:	39403-1729
Country	:	US
Telephone Number	:	601-545-8700
Fax Number	:	601-582-5461

Provider Business Practice Location Address
First Line	:	404 MAIN ST
Second Line	:
City	:	NEW AUGUSTA
State	:	MS
Zip	:	39462-0000
Country	:	US
Telephone Number	:	601-964-8391
Fax Number	:	601-964-8393

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/10/2006
Last Update Date	:	07/08/2007

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