Provider Demographics
NPI:1457595084
Name:TODD, TRACIE LYNN (RN, APN, PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:TRACIE
Middle Name:LYNN
Last Name:TODD
Suffix:
Gender:F
Credentials:RN, APN, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:394 W MAIN ST
Mailing Address - Street 2:SUITE A21
Mailing Address - City:HENDERSONVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37075-3348
Mailing Address - Country:US
Mailing Address - Phone:615-431-2833
Mailing Address - Fax:615-827-0008
Practice Address - Street 1:394 W MAIN ST
Practice Address - Street 2:SUITE A21
Practice Address - City:HENDERSONVILLE
Practice Address - State:TN
Practice Address - Zip Code:37075-3348
Practice Address - Country:US
Practice Address - Phone:615-431-2833
Practice Address - Fax:615-827-0008
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-27
Last Update Date:2016-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN167754163WP0809X
TN14488363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1515762Medicaid
103I501631Medicare PIN