Provider Demographics
NPI:1770906521
Name:NORRIS, TRACIE (PT)
Entity type:Individual
Prefix:
First Name:TRACIE
Middle Name:
Last Name:NORRIS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4501 STILLWATER CV
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72404-9107
Mailing Address - Country:US
Mailing Address - Phone:870-243-5261
Mailing Address - Fax:
Practice Address - Street 1:1107 E MATTHEWS AVE
Practice Address - Street 2:STE. 100
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-4315
Practice Address - Country:US
Practice Address - Phone:870-933-6393
Practice Address - Fax:870-933-6763
Is Sole Proprietor?:No
Enumeration Date:2014-01-30
Last Update Date:2014-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT 3797225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARPENDINGMedicaid