Provider Demographics
NPI:1972722668
Name:ETHRIDGE, TRACY WHITE (RN-BC, CNS, LPC)
Entity Type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:WHITE
Last Name:ETHRIDGE
Suffix:
Gender:F
Credentials:RN-BC, CNS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 PERIMETER PARK DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MORRISVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27560-8442
Mailing Address - Country:US
Mailing Address - Phone:252-962-5000
Mailing Address - Fax:
Practice Address - Street 1:2301 MEDPARK DR
Practice Address - Street 2:
Practice Address - City:ROCKY MOUNT
Practice Address - State:NC
Practice Address - Zip Code:27804-2288
Practice Address - Country:US
Practice Address - Phone:252-962-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2016-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4902101YP2500X
NC131546364SP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional