Provider Demographics
NPI:1639700602
Name:STAFFORD, TRACI M (CRNP)
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:M
Last Name:STAFFORD
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1118 ROSS CLARK CIR STE 100
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36301-3023
Mailing Address - Country:US
Mailing Address - Phone:334-794-1148
Mailing Address - Fax:334-793-1954
Practice Address - Street 1:1118 ROSS CLARK CIR STE 100
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36301-3023
Practice Address - Country:US
Practice Address - Phone:334-794-1148
Practice Address - Fax:334-793-1954
Is Sole Proprietor?:No
Enumeration Date:2020-01-29
Last Update Date:2020-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-122428363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily