Provider Demographics
NPI:1962865659
Name:FULLOVE, TRACIE (MD)
Entity Type:Individual
Prefix:
First Name:TRACIE
Middle Name:
Last Name:FULLOVE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:607 HAMPTON CIR APT G
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39211-2334
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3162 W MARTIN LUTHER KING BLVD STE 13-14
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72704-7679
Practice Address - Country:US
Practice Address - Phone:479-935-4834
Practice Address - Fax:479-249-9879
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-31
Last Update Date:2019-06-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ARE-11276207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine