Provider Demographics
NPI:1063799856
Name:ADKISSON, GRACIE MAE (PMHNP-BC)
Entity type:Individual
Prefix:MS
First Name:GRACIE
Middle Name:MAE
Last Name:ADKISSON
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5812 MCKNIGHT RD
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-0960
Mailing Address - Country:US
Mailing Address - Phone:903-278-5906
Mailing Address - Fax:
Practice Address - Street 1:2301 PECAN ST
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:AR
Practice Address - Zip Code:71854-3656
Practice Address - Country:US
Practice Address - Phone:903-278-5906
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-08
Last Update Date:2023-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP126190363LP0808X
VA0024177015363LP0808X
AZAP4254363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXAP126190OtherSTATE LICENSE NUMBER