Provider Demographics
NPI:1497937577
Name:EDWARDS, TRACY SHAWN (APN)
Entity Type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:SHAWN
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:62 JAMESTOWN DR
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERS
Mailing Address - State:MO
Mailing Address - Zip Code:63376-1309
Mailing Address - Country:US
Mailing Address - Phone:314-667-5959
Mailing Address - Fax:
Practice Address - Street 1:1090 ARNOLD DR
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK AFB
Practice Address - State:AR
Practice Address - Zip Code:72099-3309
Practice Address - Country:US
Practice Address - Phone:501-987-3080
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-30
Last Update Date:2019-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO151223163W00000X
MO2012038001363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No163W00000XNursing Service ProvidersRegistered Nurse