Provider Demographics
NPI:1962628966
Name:SUBER, TRACI DAVIS (WHNP)
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:DAVIS
Last Name:SUBER
Suffix:
Gender:F
Credentials:WHNP
Other - Prefix:
Other - First Name:TRACI
Other - Middle Name:DAVIS
Other - Last Name:SPEIGHTS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:415 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7246
Mailing Address - Country:US
Mailing Address - Phone:601-268-5640
Mailing Address - Fax:601-579-5240
Practice Address - Street 1:421 S 28TH AVE STE 200
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-7208
Practice Address - Country:US
Practice Address - Phone:601-268-5640
Practice Address - Fax:601-579-5240
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS814179363L00000X
MSR814179363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00118984Medicaid
MS12181303OtherCAQH ID #
MS2285175OtherUNITED HEALTHCARE
MS7059463OtherAETNA
MS500021510Medicare PIN