Provider Demographics
NPI:1548741895
Name:BENNETT, TRACY LYNNE (APRN)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:LYNNE
Last Name:BENNETT
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6262 HIGHWAY 316 S
Mailing Address - Street 2:
Mailing Address - City:MARVELL
Mailing Address - State:AR
Mailing Address - Zip Code:72366-9439
Mailing Address - Country:US
Mailing Address - Phone:870-714-0453
Mailing Address - Fax:
Practice Address - Street 1:6262 HIGHWAY 316 S
Practice Address - Street 2:
Practice Address - City:MARVELL
Practice Address - State:AR
Practice Address - Zip Code:72366-9439
Practice Address - Country:US
Practice Address - Phone:870-714-0453
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-24
Last Update Date:2018-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA005840363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner