Provider Demographics
NPI:1316392384
Name:BEASLEY, TRACY (NP)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:BEASLEY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:532 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:MS
Mailing Address - Zip Code:39350-2562
Mailing Address - Country:US
Mailing Address - Phone:601-781-8677
Mailing Address - Fax:601-676-0550
Practice Address - Street 1:532 MAIN ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:MS
Practice Address - Zip Code:39350-2562
Practice Address - Country:US
Practice Address - Phone:601-781-8677
Practice Address - Fax:601-676-0550
Is Sole Proprietor?:No
Enumeration Date:2016-04-27
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS851359363LA2200X, 363LG0600X, 363LP2300X
TXAP129485363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX488981ZUNAMedicare UPIN