Provider Demographics
NPI:1023270790
Name:FISHER, TRACY LYNN (APN, NP-C)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:LYNN
Last Name:FISHER
Suffix:
Gender:F
Credentials:APN, NP-C
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 130
Mailing Address - Street 2:
Mailing Address - City:RATCLIFF
Mailing Address - State:AR
Mailing Address - Zip Code:72951-0130
Mailing Address - Country:US
Mailing Address - Phone:479-635-0091
Mailing Address - Fax:479-635-2010
Practice Address - Street 1:4900 KELLEY HWY
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72904-5000
Practice Address - Country:US
Practice Address - Phone:479-785-5700
Practice Address - Fax:479-785-5708
Is Sole Proprietor?:No
Enumeration Date:2008-06-25
Last Update Date:2013-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA03126363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200200260AMedicaid
MO1023270790Medicaid
AR168417758Medicaid
AR168417758Medicaid