Provider Demographics
NPI:1376385005
Name:CHILDRESS, TRACI L (APRN, PMHNP-BC)
Entity type:Individual
Prefix:
First Name:TRACI
Middle Name:L
Last Name:CHILDRESS
Suffix:
Gender:F
Credentials:APRN, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:278 WOLFE LAUREL DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT CARMEL
Mailing Address - State:TN
Mailing Address - Zip Code:37645-3041
Mailing Address - Country:US
Mailing Address - Phone:423-276-2665
Mailing Address - Fax:
Practice Address - Street 1:1276 GILBREATH DR
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37614-6503
Practice Address - Country:US
Practice Address - Phone:423-439-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-12
Last Update Date:2024-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2024000452363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health