Provider Demographics
NPI:1780917443
Name:MAYS, TRACEY L (FNP)
Entity type:Individual
Prefix:
First Name:TRACEY
Middle Name:L
Last Name:MAYS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3964 GOODMAN RD E STE 128-129
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38672-8761
Mailing Address - Country:US
Mailing Address - Phone:662-655-0456
Mailing Address - Fax:662-655-0457
Practice Address - Street 1:3964 GOODMAN RD E STE 128-129
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38672-8761
Practice Address - Country:US
Practice Address - Phone:662-655-0456
Practice Address - Fax:662-655-0457
Is Sole Proprietor?:No
Enumeration Date:2009-09-14
Last Update Date:2023-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR868008363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS000030680Medicaid
MS302I502670Medicare PIN