Provider Demographics
NPI:1740405711
Name:TAYLOR, TRACY HUNTER (APRN, PMHNP-BC; LMT)
Entity Type:Individual
Prefix:MR
First Name:TRACY
Middle Name:HUNTER
Last Name:TAYLOR
Suffix:
Gender:M
Credentials:APRN, PMHNP-BC; LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1107 E MARSHALL AVE
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75601-5602
Mailing Address - Country:US
Mailing Address - Phone:903-758-2610
Mailing Address - Fax:903-758-7081
Practice Address - Street 1:425 N FREDONIA ST
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75601-6464
Practice Address - Country:US
Practice Address - Phone:903-758-2610
Practice Address - Fax:903-758-7081
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP145177363L00000X, 363LP0808X
TX864711363LP0808X
225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXAP145177OtherTEXAS APRN LICENSE