Provider Demographics
NPI:1285967547
Name:RHINEWALT, TRACY B (MSN FNP BC)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:B
Last Name:RHINEWALT
Suffix:
Gender:F
Credentials:MSN FNP BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 23666
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39225-3666
Mailing Address - Country:US
Mailing Address - Phone:601-200-4749
Mailing Address - Fax:601-200-5929
Practice Address - Street 1:971 LAKELAND DR
Practice Address - Street 2:SUITE 657
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4643
Practice Address - Country:US
Practice Address - Phone:601-200-2780
Practice Address - Fax:601-200-2788
Is Sole Proprietor?:No
Enumeration Date:2009-09-17
Last Update Date:2015-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR865510364SF0001X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SF0001XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistFamily Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08227549Medicaid