Provider Demographics
NPI:1780132449
Name:SMALL, TRACEY L (APRN, PMHNP-BC)
Entity type:Individual
Prefix:
First Name:TRACEY
Middle Name:L
Last Name:SMALL
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 1:231 S 30TH ST
Mailing Address - Street 2:
Mailing Address - City:ENID
Mailing Address - State:OK
Mailing Address - Zip Code:73701-6455
Mailing Address - Country:US
Mailing Address - Phone:580-233-2900
Mailing Address - Fax:580-233-2902
Practice Address - Street 1:231 S 30TH ST
Practice Address - Street 2:
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73701-6455
Practice Address - Country:US
Practice Address - Phone:405-372-2202
Practice Address - Fax:405-445-3780
Is Sole Proprietor?:No
Enumeration Date:2016-09-12
Last Update Date:2023-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK51535163W00000X, 363LP0808X
1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical