Provider Demographics
NPI:1861019721
Name:CRUMP, TRACI C
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:C
Last Name:CRUMP
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TRACI
Other - Middle Name:C
Other - Last Name:BAKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNP
Mailing Address - Street 1:1 MEDICAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:AR
Mailing Address - Zip Code:72015-3353
Mailing Address - Country:US
Mailing Address - Phone:501-776-6000
Mailing Address - Fax:501-776-6178
Practice Address - Street 1:1 MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:AR
Practice Address - Zip Code:72015-3353
Practice Address - Country:US
Practice Address - Phone:501-776-6000
Practice Address - Fax:501-776-6178
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-26
Last Update Date:2020-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA005931363LA2200X, 363LG0600X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute CareGroup - Multi-Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology