Provider Demographics
NPI:1740726660
Name:SOUTHERN, TRACY (APRN)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:SOUTHERN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1717 S RANGE LINE RD STE B
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64804-3224
Mailing Address - Country:US
Mailing Address - Phone:417-623-2207
Mailing Address - Fax:
Practice Address - Street 1:1717 S RANGE LINE RD STE B
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-3224
Practice Address - Country:US
Practice Address - Phone:417-623-2207
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-17
Last Update Date:2022-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013023791363LF0000X
KS79397363LF0000X
MO2017001675363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily