Provider Demographics
NPI:1669466710
Name:GEORGE, TRACY PRIVETTE (FNP)
Entity Type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:PRIVETTE
Last Name:GEORGE
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 1:230 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:LATTA
Mailing Address - State:SC
Mailing Address - Zip Code:29565-1306
Mailing Address - Country:US
Mailing Address - Phone:843-752-7667
Mailing Address - Fax:
Practice Address - Street 1:201 W HAMPTON ST
Practice Address - Street 2:
Practice Address - City:DILLON
Practice Address - State:SC
Practice Address - Zip Code:29536-3333
Practice Address - Country:US
Practice Address - Phone:843-774-5611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-06
Last Update Date:2008-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCAPN1519363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP0575Medicaid
SCGP1977Medicare ID - Type Unspecified
SCNP0575Medicaid