Provider Demographics
NPI:1417388232
Name:TELLO, TRACEY LORENA (CSFA, ST)
Entity Type:Individual
Prefix:MISS
First Name:TRACEY
Middle Name:LORENA
Last Name:TELLO
Suffix:
Gender:F
Credentials:CSFA, ST
Other - Prefix:
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Mailing Address - Street 1:931 MONROE DR NE
Mailing Address - Street 2:SUITE 102 #641
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30308-1793
Mailing Address - Country:US
Mailing Address - Phone:404-312-1633
Mailing Address - Fax:
Practice Address - Street 1:931 MONROE DRIVE NE
Practice Address - Street 2:SUITE 102 #641
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30308-7132
Practice Address - Country:US
Practice Address - Phone:404-312-1633
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-04
Last Update Date:2018-11-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA146587363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical