Provider Demographics
NPI:1164562476
Name:SOUTHERLAND, TRACY SHAREE (RN)
Entity Type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:SHAREE
Last Name:SOUTHERLAND
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:552 JIM FOX RD
Mailing Address - Street 2:
Mailing Address - City:GREENEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37743-4108
Mailing Address - Country:US
Mailing Address - Phone:423-823-0023
Mailing Address - Fax:
Practice Address - Street 1:810 W CHURCH ST
Practice Address - Street 2:
Practice Address - City:GREENEVILLE
Practice Address - State:TN
Practice Address - Zip Code:37745-3285
Practice Address - Country:US
Practice Address - Phone:423-798-1749
Practice Address - Fax:423-798-1755
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRN0000149369163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse