Basic Information
| Provider Information | |||||||||
| NPI: | 1285967547 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RHINEWALT | ||||||||
| FirstName: | TRACY | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | MSN FNP BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 23666 | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392253666 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012004749 | ||||||||
| FaxNumber: | 6012005929 | ||||||||
| Practice Location | |||||||||
| Address1: | 971 LAKELAND DR | ||||||||
| Address2: | SUITE 657 | ||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392164643 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012002780 | ||||||||
| FaxNumber: | 6012002788 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/17/2009 | ||||||||
| LastUpdateDate: | 03/20/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 364SF0001X | R865510 | MS | Y | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Family Health | 363LF0000X | R865510 | MS | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 08227549 | 05 | MS | MEDICAID |