Basic Information
| Provider Information | |||||||||
| NPI: | 1861524449 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BALLARD | ||||||||
| FirstName: | TRACY | ||||||||
| MiddleName: | MORRIS | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 602373 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282602373 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 310 LONG SHOALS RD | ||||||||
| Address2: | SUITE 310 | ||||||||
| City: | ARDEN | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287048794 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8282138235 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/10/2007 | ||||||||
| LastUpdateDate: | 08/23/2016 | ||||||||
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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 | 600021 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LG0600X | 600021 | NC | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology |
ID Information
| ID | Type | State | Issuer | Description | 1861524449 | 05 | NC | MEDICAID |