Provider Demographics
NPI:1235619206
Name:BURNS, TRACY ELLIS (PMHNP)
Entity Type:Individual
Prefix:MS
First Name:TRACY
Middle Name:ELLIS
Last Name:BURNS
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6880 COBBLESTONE BLVD
Mailing Address - Street 2:STE 2
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38672-9313
Mailing Address - Country:US
Mailing Address - Phone:662-638-3757
Mailing Address - Fax:
Practice Address - Street 1:5699 GETWELL RD BLDG H1
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38672-7311
Practice Address - Country:US
Practice Address - Phone:662-510-8606
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-18
Last Update Date:2019-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS902868363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health