Provider Demographics
NPI:1154550101
Name:DERR, TRACY ANN (LPN)
Entity type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:ANN
Last Name:DERR
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MRS
Other - First Name:TRACY
Other - Middle Name:ANN
Other - Last Name:DERR
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPN
Mailing Address - Street 1:1238 GADD RD
Mailing Address - Street 2:
Mailing Address - City:HIXSON
Mailing Address - State:TN
Mailing Address - Zip Code:37343-3917
Mailing Address - Country:US
Mailing Address - Phone:423-875-4806
Mailing Address - Fax:423-874-0094
Practice Address - Street 1:1238 GADD RD.
Practice Address - Street 2:
Practice Address - City:HIXSON
Practice Address - State:TN
Practice Address - Zip Code:37343
Practice Address - Country:US
Practice Address - Phone:423-875-4806
Practice Address - Fax:423-874-0094
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-13
Last Update Date:2009-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000066774164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse