Provider Demographics
NPI:1568554590
Name:BILLINGSLEY, TRACI RENEE (PA)
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:RENEE
Last Name:BILLINGSLEY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2175 BRADLEY AVE
Mailing Address - Street 2:
Mailing Address - City:GADSDEN
Mailing Address - State:AL
Mailing Address - Zip Code:35903-4651
Mailing Address - Country:US
Mailing Address - Phone:256-393-3388
Mailing Address - Fax:
Practice Address - Street 1:2505 US HIGHWAY 431
Practice Address - Street 2:
Practice Address - City:BOAZ
Practice Address - State:AL
Practice Address - Zip Code:35957
Practice Address - Country:US
Practice Address - Phone:256-393-3388
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2013-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPA-157363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
S70430Medicare UPIN
051557272BILMedicare ID - Type Unspecified