Provider Demographics
NPI:1306376199
Name:YOUNG, TRACIE (NP)
Entity Type:Individual
Prefix:
First Name:TRACIE
Middle Name:
Last Name:YOUNG
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 LAKESHORE PKWY
Mailing Address - Street 2:
Mailing Address - City:ROCK HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29730-4273
Mailing Address - Country:US
Mailing Address - Phone:1803-909-9751
Mailing Address - Fax:
Practice Address - Street 1:1136 KINCAID BRIDGE RD STE A
Practice Address - Street 2:
Practice Address - City:WINNSBORO
Practice Address - State:SC
Practice Address - Zip Code:29180-7116
Practice Address - Country:US
Practice Address - Phone:803-635-1052
Practice Address - Fax:803-712-9724
Is Sole Proprietor?:No
Enumeration Date:2017-06-14
Last Update Date:2022-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC20610363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily