Provider Demographics
NPI:1568753127
Name:EDWARDS, TRACY LEE (PMHNP)
Entity Type:Individual
Prefix:MS
First Name:TRACY
Middle Name:LEE
Last Name:EDWARDS
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 1:220 W COLFAX AVE STE 400
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46601-1635
Mailing Address - Country:US
Mailing Address - Phone:574-546-1900
Mailing Address - Fax:
Practice Address - Street 1:220 W COLFAX AVE STE 400
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-1635
Practice Address - Country:US
Practice Address - Phone:574-546-1900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-29
Last Update Date:2018-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX607986364SP0809X
IN71007338A363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult