Provider Demographics
NPI:1194863472
Name:ANDERSON, TRACY SELINA (RN CM)
Entity Type:Individual
Prefix:MS
First Name:TRACY
Middle Name:SELINA
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:RN CM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9054
Mailing Address - Street 2:
Mailing Address - City:GRAY
Mailing Address - State:TN
Mailing Address - Zip Code:37615-9054
Mailing Address - Country:US
Mailing Address - Phone:423-467-3600
Mailing Address - Fax:423-467-3696
Practice Address - Street 1:3169 2ND AVENUE EAST
Practice Address - Street 2:
Practice Address - City:BIG STONE GAP
Practice Address - State:VA
Practice Address - Zip Code:24219
Practice Address - Country:US
Practice Address - Phone:276-523-8300
Practice Address - Fax:276-523-6964
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001169659163W00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered163W00000XNursing Service ProvidersRegistered Nurse
Not Answered171M00000XOther Service ProvidersCase Manager/Care Coordinator