Provider Demographics
NPI:1295853174
Name:POWELL, TRACY ELAINE (CANP)
Entity Type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:ELAINE
Last Name:POWELL
Suffix:
Gender:F
Credentials:CANP
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:ELAINE
Other - Last Name:CARR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:102 CAROLINAS WAY
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30215-8022
Mailing Address - Country:US
Mailing Address - Phone:678-817-1659
Mailing Address - Fax:
Practice Address - Street 1:1365B CLIFTON RD NE
Practice Address - Street 2:SUITE1400
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30322-1013
Practice Address - Country:US
Practice Address - Phone:404-778-4898
Practice Address - Fax:404-778-4006
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAR092714363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
50BBJHKMedicare ID - Type Unspecified