Provider Demographics
NPI:1417283839
Name:ANDERSON, TRACI LYNN (NNP-BC)
Entity type:Individual
Prefix:
First Name:TRACI
Middle Name:LYNN
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:NNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 MORROW RD
Mailing Address - Street 2:
Mailing Address - City:NEWBORN
Mailing Address - State:GA
Mailing Address - Zip Code:30056-2602
Mailing Address - Country:US
Mailing Address - Phone:770-784-5756
Mailing Address - Fax:
Practice Address - Street 1:500 MEDICAL CENTER BLVD
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-8708
Practice Address - Country:US
Practice Address - Phone:678-312-3958
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-20
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN160024363LN0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0005XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal, Critical Care