Provider Demographics
NPI:1689256075
Name:WILSON, TRACY DENISE (FNP)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:DENISE
Last Name:WILSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4055 N PARK LOOP
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38152-4220
Mailing Address - Country:US
Mailing Address - Phone:901-678-2003
Mailing Address - Fax:
Practice Address - Street 1:1911 MISSION 66 STE B
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39180-3762
Practice Address - Country:US
Practice Address - Phone:601-665-4162
Practice Address - Fax:855-830-3484
Is Sole Proprietor?:No
Enumeration Date:2021-04-25
Last Update Date:2022-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS904985363LF0000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program