Provider Demographics
NPI:1568844462
Name:HARRISON, TRACEY (CRNP)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:
Last Name:HARRISON
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:TRACEY
Other - Middle Name:
Other - Last Name:HICKS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CRNP
Mailing Address - Street 1:2010 WYNDGATE LOOP
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36117-8043
Mailing Address - Country:US
Mailing Address - Phone:334-782-1551
Mailing Address - Fax:
Practice Address - Street 1:2105 E SOUTH BLVD
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36116-2409
Practice Address - Country:US
Practice Address - Phone:334-288-2100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-26
Last Update Date:2015-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-080478363LN0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0005XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal, Critical Care