Provider Demographics
NPI:1942321575
Name:MITCHEM-GREEN, TRACIE LEDORA (FNP)
Entity type:Individual
Prefix:
First Name:TRACIE
Middle Name:LEDORA
Last Name:MITCHEM-GREEN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:295 NW COMMONS LOOP # 115-105
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32055-7721
Mailing Address - Country:US
Mailing Address - Phone:803-381-7690
Mailing Address - Fax:
Practice Address - Street 1:295 NW COMMONS LOOP # 115-105
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32055-7721
Practice Address - Country:US
Practice Address - Phone:803-381-7690
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-02
Last Update Date:2018-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2981363LP2300X, 363L00000X
FL9304575363LF0000X
FLARNP9304575363LP2300X
NY342892363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner