Basic Information
| Provider Information | |||||||||
| NPI: | 1689256075 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | TRACY | ||||||||
| MiddleName: | DENISE | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4055 N PARK LOOP | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381524220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9016782003 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1911 MISSION 66 STE B | ||||||||
| Address2: | |||||||||
| City: | VICKSBURG | ||||||||
| State: | MS | ||||||||
| PostalCode: | 391803762 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6016654162 | ||||||||
| FaxNumber: | 8558303484 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2021 | ||||||||
| LastUpdateDate: | 04/19/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 904985 | MS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.