Basic Information
| Provider Information | |||||||||
| NPI: | 1487613774 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MULLINS | ||||||||
| FirstName: | TRACEY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 369 | ||||||||
| Address2: | |||||||||
| City: | VAIDEN | ||||||||
| State: | MS | ||||||||
| PostalCode: | 391760369 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6624645470 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1401 RIVER RD | ||||||||
| Address2: | |||||||||
| City: | GREENWOOD | ||||||||
| State: | MS | ||||||||
| PostalCode: | 389304030 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6624597000 | ||||||||
| FaxNumber: | 6624591147 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2006 | ||||||||
| LastUpdateDate: | 07/25/2011 | ||||||||
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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 | 363L00000X | R681857 | MS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 00118843 | 05 | MS | MEDICAID |