Provider Demographics
NPI:1730418427
Name:SCRUGGS-BLANKENSHIP, TRACY (APN, FNP-BC)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:SCRUGGS-BLANKENSHIP
Suffix:
Gender:F
Credentials:APN, 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 400
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38302-0400
Mailing Address - Country:US
Mailing Address - Phone:731-423-8697
Mailing Address - Fax:731-422-5743
Practice Address - Street 1:700 W FOREST AVE STE 300
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301-3946
Practice Address - Country:US
Practice Address - Phone:731-422-0213
Practice Address - Fax:731-422-0475
Is Sole Proprietor?:No
Enumeration Date:2009-12-09
Last Update Date:2019-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN14857363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1518638Medicaid
TNP00844591Medicare PIN
TN1518638Medicaid